Juniper Village At Bucks County Rehab And Skd Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Bensalem, Pennsylvania.
- Location
- 3200 Bensalem Boulevard, Bensalem, Pennsylvania 19020
- CMS Provider Number
- 395864
- Inspections on file
- 17
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Juniper Village At Bucks County Rehab And Skd Care during CMS and state inspections, most recent first.
The facility did not provide the required RN coverage on two separate shifts, resulting in no RN hours being recorded when a minimum of 8.0 hours was required for each shift.
A resident who was cognitively intact signed a binding arbitration agreement at admission without being informed of the right to rescind the agreement within 30 days or that the agreement does not prevent communication with regulatory officials. Both the social worker and administrator confirmed they did not provide this information during the review process, and the resident was unaware of these rights.
A resident experienced a significant weight loss following a hospital stay and return to the facility. Although the dietician was eventually notified and offered nutritional supplements, the care plan was not updated to address the resident's recent weight loss or interventions, as required by facility policy and regulations.
The facility did not ensure ongoing water testing and compliance with its water management plan for Legionella prevention, as the last water test was completed over a year prior to the survey. Staff confirmed that required procedures and documentation were not maintained, resulting in a failure to adhere to CDC and CMS guidelines for waterborne pathogen control.
A facility failed to document a resident's advanced directives in their electronic medical record. Despite having a signed POLST form indicating DNR status and specific medical treatment preferences, these directives were not reflected in the resident's records. Staff interviews confirmed the oversight, highlighting a lapse in adhering to the facility's policy on maintaining accurate records.
The facility failed to notify the State Long Term Care Ombudsman of facility-initiated discharges for three residents. Despite informing responsible parties of hospital transfers, there was no documented evidence of Ombudsman notification. The Facility Administrator confirmed the lack of a process for notifying the Ombudsman of such discharges.
The facility failed to develop baseline care plans within 48 hours of admission for four residents, as required. A resident with multiple diagnoses, including reduced mobility, had no baseline care plan, and an error in the admission MDS regarding dental status was noted. Another resident with chronic venous hypertension and ulcers lacked a care plan for skin integrity. Two other residents had care plans without necessary interventions. Interviews confirmed the absence of timely baseline care plans.
The facility failed to create and implement individualized care plans for two residents, leading to deficiencies in addressing their specific needs. One resident, who was edentulous, had no care plan for dental issues, while another resident with chronic ulcers had care plans lacking specific interventions. This indicates a failure to provide comprehensive care as required by regulations.
The facility failed to timely address pharmacy recommendations for three residents, leading to deficiencies in medication management. A resident with Major Depressive Disorder experienced a 33-day delay in addressing a recommended dose reduction. Another resident's medication evaluation and adjustment were delayed, and a third resident's medication record had irregularities that were not reviewed by a physician. These issues were confirmed by the DON.
The facility failed to implement an effective infection control program, lacking systems to track infections and review antibiotic use as per their policy. An interview with a staff member confirmed the absence of these critical components, indicating non-compliance with established procedures.
Failure to Meet Minimum RN Staffing Requirements
Penalty
Summary
The facility failed to comply with Pennsylvania state regulations requiring a minimum of one registered nurse (RN) per 250 residents on all shifts. A review of the facility's nursing staff ratio for the week of July 29, 2025, through August 5, 2025, showed that on two separate shifts, the required RN coverage was not met. Specifically, there was no RN coverage for the entire night shift on July 31, 2025, and no RN coverage for the entire evening shift on August 2, 2025, despite a minimum of 8.0 hours being required for each shift. These findings were discussed with the facility's administrator.
Plan Of Correction
No negative outcomes occurred due to this deficient practice. DON/designee will review and approve all schedules to ensure one RN is scheduled for each shift. DON/designee will audit staffing daily for 4 weeks, then weekly for 2 months, reporting results to the QA Committee. Noncompliance will be corrected immediately.
Failure to Inform Resident of Arbitration Agreement Rights
Penalty
Summary
The facility failed to ensure that a resident was properly informed about the terms and rights associated with signing a binding arbitration agreement upon admission. Although the resident was cognitively intact, as indicated by a BIMS score of 15 on the admission MDS, the review of the signed arbitration agreement revealed that it lacked documentation of who reviewed the agreement with the resident. Interviews with the social worker and the nursing home administrator confirmed that neither informed the resident of their right to rescind the agreement within 30 days of signing, nor did they explain that the agreement does not prevent communication with federal, state, or local officials, including surveyors and ombudsmen. Further interviews with the resident and their spouse revealed that the resident was unaware of the right to rescind the agreement or the ability to communicate with regulatory officials despite having signed the document. Both the social worker and the administrator admitted to omitting these critical explanations during their review of the arbitration agreement with residents. The deficiency was confirmed by the administrator, who acknowledged that residents were not informed of these rights in a language they could understand, as required.
Failure to Update Care Plan for Significant Weight Loss
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan to address a significant weight loss in a resident. The facility's policy requires that residents experiencing unintended weight loss be assessed by the interdisciplinary team, with interventions implemented and documented in the care plan, including measurable objectives and time frames. However, review of the clinical record for a resident who was admitted after a hospital stay, subsequently discharged back to the hospital for gastrointestinal bleeding, and then readmitted, revealed a significant weight loss of 18.8 pounds over eleven days. The resident's weight dropped from 143.8 pounds to 125.0 pounds during this period. Despite this significant weight loss, the registered dietician was only made aware of the issue several days later and, although supplemental shakes were offered and refused by the resident, the care plan was not updated to reflect the new interventions or the resident's current nutritional status. The dietician confirmed that the protocol would involve communication with nursing staff and the physician, followed by an update to the care plan, but this was not completed. The failure to update the care plan and document appropriate interventions constituted noncompliance with facility policy and regulatory requirements.
Failure to Implement and Maintain Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to develop and implement an effective water management program for the prevention, detection, and control of waterborne contaminants, specifically Legionella. According to the report, the facility's water management plan, which is contracted to an outside company, outlines procedures such as routine control measures, inspection of plumbing and hot water systems, quarterly cleaning of aerators, and regular water testing. However, documentation and staff interviews confirmed that the facility did not ensure ongoing water testing and compliance with its own water management plan, as the last recorded water test was completed on February 18, 2023. This deficiency was identified through observation, policy review, and staff interviews, which revealed that the facility did not adhere to CDC and CMS guidelines requiring regular risk assessments, implementation of water management programs, and documentation of testing and corrective actions. The Environmental Director and Nursing Home Administrator confirmed the lapse in water testing and compliance, indicating a failure to follow established protocols for minimizing the risk of Legionella and other waterborne pathogens in the facility's water system.
Failure to Document Advanced Directives in Resident's Record
Penalty
Summary
The facility failed to ensure that advanced directives were accurately reflected in the records of a resident, identified as Resident R70. Upon review of the clinical records and interviews with staff, it was found that Resident R70's electronic medical record did not include their DNR status or any advanced directives. This omission was despite the resident having a completed and signed POLST form indicating their preferences for medical interventions, including a DNR order, limited additional interventions, and no artificial hydration or nutrition by tube. The POLST form was signed by both the physician and Resident R70. Interviews with facility staff, including Employee E4 and the Facility Administrator, confirmed the absence of the advanced directives in the electronic medical record. Employee E4 acknowledged that Resident R70 had signed a POLST form and expressed specific medical treatment preferences, yet these were not documented in the electronic system. The Facility Administrator also confirmed the lack of documentation for Resident R70's advanced directives in the electronic medical record, indicating a failure to adhere to the facility's policy on maintaining accurate records of residents' advanced directives.
Failure to Notify Ombudsman of Facility-Initiated Discharges
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman of facility-initiated emergency transfers and discharges for three residents. Resident R73 was discharged to the hospital on July 26, 2024, but there was no documented evidence that the Ombudsman was informed of this discharge. Similarly, Resident R74 was transferred to the hospital on two occasions, May 19, 2024, and June 23, 2024, without notification to the Ombudsman. Resident R75 was also discharged to the hospital on July 25, 2024, with no evidence of Ombudsman notification. Interviews with the Facility Administrator, Employee E1, confirmed that the facility lacked a process for providing the Ombudsman with copies of discharge notices. Employee E1 acknowledged that the Ombudsman was not notified of the discharges for Residents R73, R74, and R75. This oversight was identified during a review of clinical records and facility documents, which revealed the absence of documented notifications to the Ombudsman for these facility-initiated discharges.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for four residents, as required by regulations. The facility's policy on care planning did not address the creation of a baseline care plan. Resident R14 was admitted with multiple diagnoses, including reduced mobility and cognitive communication deficit, but no baseline care plan was established. Additionally, an error was found in the admission MDS regarding the resident's dental status, which was not corrected. Observations revealed that Resident R14 was edentulous and not wearing dentures, which he reportedly did not like wearing. Resident R70 was admitted with chronic venous hypertension and multiple non-pressure ulcers, yet no baseline care plan for skin integrity or wound care was in place. Resident R9, admitted with sepsis and other conditions, had a care plan that lacked necessary interventions. Similarly, Resident R120, admitted with a thoracic spine fracture and bipolar disorder, had a care plan without interventions. Interviews confirmed that baseline care plans were not completed within the required timeframe for Residents R9 and R120.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized comprehensive care plans for two residents, leading to deficiencies in addressing their specific needs. Resident R14, who was admitted with conditions including reduced mobility and cognitive communication deficit, was observed to be edentulous and not wearing dentures during a meal. Despite having dentures, the resident expressed a preference not to wear them. However, there was no care plan in place to address the resident's dental issues, indicating a lack of individualized planning for this aspect of care. Similarly, Resident R70, admitted with multiple chronic ulcers and other health issues, had a care plan for venous stasis ulcers that lacked specific interventions. Additionally, care plans for falls, impaired vision, and potential pressure ulcers were also missing interventions. This lack of detailed planning and intervention documentation highlights the facility's failure to provide comprehensive care plans tailored to the residents' needs, as required by their own policies and federal and state regulations.
Delayed Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to act on pharmacy recommendations in a timely manner for three residents, leading to deficiencies in medication management. Resident R10, who was admitted with Major Depressive Disorder, had a pharmacy recommendation for a gradual dose reduction of Mirtazapine and Citalopram on August 15, 2024. However, the attending physician did not address this recommendation until September 17, 2024, resulting in a 33-day delay. This delay was confirmed by the Director of Nursing (DON) during an interview. For Resident R14, the pharmacy recommended evaluating the necessity of atorvastatin, monitoring symptoms, and adjusting the Eliquis dose. Despite the DON signing off on the pharmacy review, the physician reviewed the recommendations late. Additionally, Resident R70's pharmacy consultation report noted irregularities in the medication administration record, including incomplete directions and missing strength for ascorbic acid. The report lacked the physician's signature, indicating that the recommendations were not reviewed. These issues were confirmed by the DON, highlighting a pattern of delayed response to pharmacy recommendations.
Failure in Infection Control and Antibiotic Stewardship
Penalty
Summary
The facility failed to establish an effective infection control program related to infection surveillance and periodic review of antibiotic use. The facility's policy on antibiotic stewardship outlines the need for a program to promote appropriate antibiotic use and optimize infection treatment while reducing adverse events. However, the facility did not have documented evidence of tracking infections or conducting periodic reviews of antibiotic use, as required by their policy. This lack of documentation indicates a failure to adhere to the established procedures for monitoring antibiotic usage patterns, reviewing antibiograms, and tracking multi-drug resistant organisms. An interview with Employee E2 confirmed that the facility lacked a system to track infections and antibiotic use, and there was no periodic review of antibiotic use in place. This deficiency was identified through observations, policy reviews, and staff interviews, highlighting a significant gap in the facility's infection control and antibiotic stewardship efforts. The absence of these critical components in the infection control program suggests non-compliance with the facility's own policies and state regulations.
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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