Lakeview Healthcare And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Smethport, Pennsylvania.
- Location
- 15 West Willow Street, Smethport, Pennsylvania 16749
- CMS Provider Number
- 395867
- Inspections on file
- 19
- Latest survey
- May 30, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lakeview Healthcare And Rehab during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including a coccyx pressure ulcer, did not have their dignity maintained during a dressing change when an LPN dated the dressing after it was applied, instead of before. The LPN acknowledged this error during an interview.
A resident with encephalopathy, seizures, and pleural effusion had a physician's order for a security bracelet alarm to be worn at all times, and staff documented its use every shift. However, the quarterly MDS assessment was incorrectly coded as not using a wander/elopement alarm, despite daily use being documented and confirmed by the RN Assessment Coordinator.
A resident with COPD, diabetes, and hypertension was observed receiving oxygen at 3.5 lpm, contrary to the physician's order for 1 lpm via nasal cannula PRN. An LPN confirmed the incorrect setting, and the administrator acknowledged the resident's tendency to alter the concentrator without evidence of routine checks to ensure compliance with the prescribed oxygen flow.
An LPN failed to remove gloves and perform hand hygiene during a dressing change for a resident with a coccyx pressure ulcer, proceeding to cleanse the wound without following infection control protocols as required by facility policy. The resident had multiple medical conditions, including a recent fracture, heart failure, dementia, and hypertension.
The facility failed to provide a written summary of the baseline care plan to five residents or their representatives, as required by policy. The clinical records lacked documentation of the summary, which should include goals, medication summaries, dietary instructions, and treatments. This deficiency was confirmed by the Nursing Home Administrator and involved residents with conditions such as high blood pressure, osteoporosis, COPD, dementia, fractures, encephalopathy, seizures, and schizophrenia.
The facility did not ensure that two residents or their representatives were invited to participate in care plan meetings, as required by policy. Despite having quarterly MDS assessments, there was no evidence of invitations or attendance at these meetings, confirmed by staff interviews.
A resident with peripheral vascular disease, heart failure, and hypokalemia experienced a fall resulting in a head laceration requiring sutures. Despite the incident, the facility did not develop a comprehensive care plan to address the fall and injury. The RN Assessment Coordinator confirmed the lack of a care plan, which should have been initiated.
The facility failed to review and revise care plans for two residents as required. One resident, with conditions including high blood pressure and osteoporosis, had 12 care plans with outdated target dates and no evidence of a care plan meeting after a recent MDS assessment. Another resident, with hypertension and anxiety, also lacked evidence of a care plan meeting post-assessment. Interviews confirmed the care plans were not reviewed or revised as required.
A facility failed to ensure accurate physician's orders for a resident who was at risk for elopement and had a wanderguard bracelet applied. Despite the resident's diagnoses of encephalopathy, osteoporosis, and seizures, and an elopement risk evaluation indicating the need for a wanderguard, the clinical record lacked a physician's order for its use. Observations confirmed the bracelet's presence, and the DON acknowledged the absence of the necessary order, highlighting a deficiency in clinical records and nursing services.
The facility failed to maintain proper care of respiratory equipment for two residents with COPD. Both residents had physician orders to change oxygen tubing weekly, but observations revealed that the tubing was not changed as ordered. The DON confirmed these oversights, indicating non-compliance with facility policy and physician orders.
Failure to Maintain Resident Dignity During Wound Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to maintain resident dignity during a wound dressing change for a resident with a coccyx pressure ulcer. The LPN was observed placing a new dressing on the resident and then dating the dressing while it was already on the resident, rather than dating it prior to application. During an interview, the LPN confirmed this practice and acknowledged that the dressing should have been dated before being placed on the resident. The resident involved had a history of a fractured right femur, heart failure, dementia, and high blood pressure, and was under physician's orders for specific wound care to the coccyx.
Inaccurate MDS Coding for Wander/Elopement Alarm Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the use of a wander/elopement alarm for one resident. According to the resident's clinical record, there was a physician's order for an alarming security bracelet to be worn at all times, and treatment administration records showed that staff checked the placement of the bracelet every shift throughout the month. However, the quarterly MDS assessment for this resident was coded as 'Not Used' for the wander/elopement alarm, despite clear evidence of daily use. This discrepancy was confirmed during an interview with the Registered Nurse Assessment Coordinator, who acknowledged that the MDS was incorrectly coded and should have indicated daily use of the alarm. The resident involved had diagnoses including encephalopathy, seizures, and pleural effusion, and had been admitted with these conditions. The failure to accurately code the MDS assessment represents a deficiency in ensuring accurate and complete medical records as required by regulation.
Failure to Administer Oxygen Therapy per Physician's Order
Penalty
Summary
The facility failed to provide oxygen therapy according to the physician's order for a resident with chronic obstructive pulmonary disease (COPD), diabetes, and high blood pressure. The physician's order specified oxygen at 1 liter per minute (lpm) via nasal cannula as needed for shortness of breath or comfort. However, observations on two separate occasions revealed the resident was receiving oxygen at 3.5 lpm, which was not in accordance with the order. A Licensed Practical Nurse confirmed that the oxygen concentrator was set at 3.5 lpm, and the Nursing Home Administrator acknowledged that the resident had a habit of changing the concentrator settings. Despite being aware of this behavior, the facility did not provide evidence of implementing routine interventions to ensure the oxygen flow rate was maintained as ordered by the physician.
Failure to Follow Infection Control Protocol During Wound Care
Penalty
Summary
A deficiency occurred when an LPN performed a dressing change for a resident with a coccyx pressure ulcer and failed to follow infection prevention and control protocols. The LPN removed the soiled dressing and continued to cleanse the wound without removing gloves or performing hand hygiene, contrary to the facility's policy which requires removal of soiled gloves and handwashing after removing the dressing. This was confirmed during an interview with the LPN, who acknowledged not changing gloves or completing hand hygiene as indicated. The resident involved had a history of fractured right femur, heart failure, dementia, and high blood pressure, and had a physician's order for wound care to the coccyx.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to residents and/or their representatives for five out of thirteen residents reviewed. The facility's policy, dated 5/2/24, mandates that a written summary of the baseline care plan, including goals, objectives, medication summaries, dietary instructions, and any services and treatments, be provided in a language understandable to the resident or their representative. This summary should also be documented in the medical record. However, the clinical records for residents with various medical conditions, such as high blood pressure, osteoporosis, depression, chronic obstructive pulmonary disease, dementia, fractures, encephalopathy, seizures, and schizophrenia, lacked evidence of such documentation. During an interview, the Nursing Home Administrator confirmed the absence of documentation for the provision of the baseline care plan summary to the residents or their representatives. This deficiency was identified for residents with significant medical conditions, including high blood pressure, osteoporosis, chronic obstructive pulmonary disease, dementia, fractures, encephalopathy, seizures, and schizophrenia. The failure to provide and document the baseline care plan summary is a violation of the facility's admissions policy as per 28 Pa. Code 201.24 (e)(4).
Failure to Involve Residents in Care Plan Development
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were offered the opportunity to participate in the development, review, and/or revision of their person-centered care plans. This deficiency was identified for two residents during a review of clinical records and staff interviews. The facility's policy requires a seven-day advance notice of care planning conferences to be provided to residents and their representatives, with records maintained of such notices. However, for two residents, there was no evidence that they or their representatives were invited to or attended care plan meetings in conjunction with their quarterly MDS assessments. Resident R9, who has diagnoses including high blood pressure, osteoporosis, and depression, had a quarterly MDS assessment with an ARD of 5/6/24, but there was no documentation of an invitation to a care plan meeting. Similarly, Resident R16, with diagnoses of hypertension, anxiety, and hyperlipidemia, had a quarterly MDS assessment with an ARD of 5/21/24, and also lacked evidence of being invited to a care plan meeting. The Registered Nurse Assessment Coordinator and the Social Worker confirmed the absence of such documentation during an interview.
Failure to Develop Comprehensive Care Plan for Resident After Fall
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident R12, who was admitted with diagnoses including peripheral vascular disease, heart failure, and hypokalemia. A progress note in the resident's clinical record indicated that the resident was found lying on the floor with a large laceration to the right side of the head, requiring transfer to the emergency room for evaluation and treatment. Upon return from the emergency room with sutures, the resident's clinical record lacked evidence of a care plan addressing the fall and head laceration. The Registered Nurse Assessment Coordinator confirmed the absence of a care plan for the incident, acknowledging that it should have been initiated.
Failure to Review and Revise Care Plans for Two Residents
Penalty
Summary
The facility failed to review and revise care plans for two residents, R9 and R16, as required by their policy. Resident R9, who was admitted with diagnoses including high blood pressure, osteoporosis, and depression, had 12 out of 22 care plans with an outstanding target date of 5/22/24. These care plans covered various problem categories such as impaired vision, respiratory impairment, pain related to osteoporosis, and risk for falls. Despite a Quarterly MDS assessment with an ARD of 5/6/24, there was no evidence of a care plan meeting being held after this date. Interviews with the Registered Nurse Assessment Coordinator and Social Worker confirmed the lack of review and revision of Resident R9's care plans. Similarly, Resident R16, admitted with hypertension, anxiety, and hyperlipidemia, had a care plan for risk for behaviors with a target date of 5/17/24. A Quarterly MDS assessment with an ARD of 5/21/24 was conducted, but the clinical record lacked evidence of a care plan meeting post-assessment. The Registered Nurse Assessment Coordinator confirmed that Resident R16's care plan was not reviewed or revised as required. These deficiencies indicate a failure to adhere to the facility's policy of quarterly care plan reviews and updates.
Deficiency in Physician's Orders for Wanderguard Bracelet
Penalty
Summary
The facility failed to ensure that physician's orders were accurate and reflected the care provided to a resident, identified as Resident R79. The resident's clinical record indicated an admission with diagnoses including encephalopathy, osteoporosis, and seizures. An elopement risk evaluation completed on June 7, 2024, determined that the resident was at risk for elopement, leading to the application of a wanderguard bracelet. However, the clinical record lacked a physician's order for the use of the wanderguard bracelet. Observations on multiple dates confirmed the presence of the wanderguard bracelet on the resident's right wrist. During an interview, the Director of Nursing confirmed the absence of a physician's order for the wanderguard bracelet, which constituted a deficiency in maintaining accurate clinical records and nursing services as per the relevant state codes.
Failure to Maintain Proper Respiratory Equipment Care
Penalty
Summary
The facility failed to maintain proper care of respiratory equipment for two residents, both of whom required respiratory care due to their medical conditions. Resident R6, diagnosed with chronic obstructive pulmonary disease (COPD), high blood pressure, and congestive heart failure, had physician orders to change oxygen tubing every Sunday night shift. However, an observation on June 16, 2024, revealed that the oxygen tubing connected to Resident R6's portable oxygen tank was dated May 20, 2024, indicating it had not been changed weekly as ordered. This was confirmed by the Director of Nursing (DON) during an interview. Similarly, Resident R17, who also had COPD, high blood pressure, and anxiety, had physician orders to change oxygen tubing every Sunday night shift. Observations on June 15 and June 16, 2024, showed that the oxygen tubing was dated June 3, 2024, and had not been changed as per the physician's orders. The DON confirmed this oversight during an interview. These findings indicate a failure to adhere to the facility's policy and physician orders regarding the maintenance of respiratory equipment, as required by 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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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