Lebanon Skilled Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lebanon, Pennsylvania.
- Location
- 900 Tuck Street, Lebanon, Pennsylvania 17042
- CMS Provider Number
- 395472
- Inspections on file
- 24
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Lebanon Skilled Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
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.
Facility staff failed to follow dialysis care policies and the care plan for a resident with diabetes mellitus, chronic kidney disease, and an upper extremity hemodialysis fistula. Despite clear directions to avoid using the arm with the dialysis access for any treatment, including blood pressure measurement, staff repeatedly documented taking blood pressure on that arm over multiple months. The DON later confirmed that the resident’s blood pressure had been measured on the arm containing the dialysis access.
A resident admitted with PTSD, depression, polyneuropathy, and insomnia, and assessed as having no cognitive impairment but needing substantial assistance with ADLs, was not evaluated for PTSD-related symptoms or triggers. The care plan did not address the resident’s trauma history, identify triggers, or include specific interventions to minimize triggers or re-traumatization. The DON confirmed that no PTSD assessment or related care planning had been completed, resulting in a deficiency in required nursing services.
The facility did not ensure that physicians acknowledged and addressed consultant pharmacist recommendations for medication regimen reviews for two residents. Clinical records showed that the pharmacist made multiple recommendations regarding these residents’ medications, but there was no documentation of the specific recommendations or any physician response or action. The DON confirmed that there was no evidence in the medical records that the physicians had addressed the pharmacist’s medication review findings, resulting in noncompliance with state management and nursing services requirements.
The facility did not ensure that two nurse aides completed the required 12 hours of annual in‑service education, including dementia management, abuse prevention, and training to address performance weaknesses. One aide had only a brief in‑service on infection control and respirator use, while another had less than four hours of training focused on safe resident handling, mechanical lift use, elopement prevention, and ethics. The DON and the NHA confirmed that the required annual in‑service training had not been completed, resulting in noncompliance with state personnel and staff development regulations.
The facility failed to report an incident of alleged neglect to state and local authorities as required by its abuse prohibition policy after a dependent resident with chronic respiratory failure, heart failure, and venous insufficiency was found with a bruise on the left forearm. Documentation showed that a NA had used the resident's forearm to roll the resident during care, and there was no evidence that a second staff member assisted or that a bed pad was used, contrary to the resident's care plan requiring 2–3 staff and a bed pad for bed mobility. The DON confirmed that the incident was not reported as required.
A resident with chronic respiratory failure, heart failure, and venous insufficiency was care planned as dependent for ADLs, with bed mobility to be performed by two to three staff using a bed pad. During care, an NA used the resident’s forearm to roll the resident without a second staff member or a bed pad, and a bruise was later observed on the forearm. The resident reported being able to reposition with one staff and a bed pad, and the DON confirmed that the bed pad was not used and that the care plan had not been updated to reflect the resident’s current bed mobility status.
A resident reported difficulty receiving hot coffee, and a test tray audit confirmed that coffee was served below the required temperature of 140°F, with a measured temperature of 128°F. Facility documentation supported the temperature requirement, and the deficiency was identified through resident interview, documentation review, and direct observation.
The facility failed to store food in a sanitary manner, as observed during a kitchen tour. Items in the walk-in cooler and freezer were found either past their labeled dates or not dated at all, contrary to the facility's policy. The Dietary Manager confirmed these items should have been dated and removed if expired.
The facility did not perform infection surveillance as required by its policy. The policy mandates regular surveillance by the Infection Preventionist, but no documentation of such surveillance was found since January 2025. The DON confirmed that monthly infection surveillance was not conducted as per the policy.
The facility did not employ a full-time qualified dietary services manager in the absence of a full-time dietitian. Interviews with the Dietary Manager and Administrator confirmed the lack of a certified dietary manager, violating 28 Pa. Code 201.18(b)(3) Management.
The facility failed to respond to a resident's call bell in a timely manner, leaving him waiting for assistance with his urinal. Another resident did not receive a scheduled shower, as documented in his care plan, impacting his quality of life. Both residents had no cognitive impairments and required specific care as per their medical conditions.
A resident was unable to attend her preferred morning activities due to the facility's failure to assist her in getting ready on time. Despite being alert and oriented, and having a care plan that encouraged participation in group activities, staff did not adhere to her preference to be up by 7:00 a.m., causing her to miss activities scheduled at 10:00 a.m. The resident, who has congestive heart failure and osteoarthritis, relies on a wheelchair and staff assistance for care.
The facility failed to develop comprehensive care plans for two residents. A resident with dementia did not have interventions for cognitive decline in their care plan, and another resident with a deep tissue injury lacked interventions for their pressure ulcer. The DON confirmed the absence of documented evidence addressing these care areas.
A resident with chronic obstructive pulmonary disease, stroke, and abnormal gait was recommended for a restorative ambulation program by physical therapy. Despite the recommendation, the resident reported insufficient assistance with walking, and documentation showed no consistent implementation of the program. The DON confirmed the absence of the program, leading to a deficiency under nursing services regulations.
The facility failed to follow physician's orders for several residents, including not documenting daily weights for residents with heart failure and chronic kidney disease, administering blood pressure medication without prior assessment, and not providing documented wound care. Additionally, a resident was observed with a compression stocking and wrap without a physician's order. The DON confirmed these deficiencies.
A facility failed to apply a prescribed splint to a resident with a right knee contracture, as ordered by the physician, to prevent further decline in range of motion. Despite the care plan and physician's order, observations over several days showed the resident without the splint, indicating a lapse in care.
A facility failed to provide adequate catheter care for a resident with an indwelling urinary catheter, as required by their policy. Additionally, another resident at risk for bladder function loss did not receive a proper incontinence assessment or program, despite frequent urinary incontinence and needing assistance with toileting. The DON confirmed the lack of documentation for the necessary assessments and care.
The facility failed to securely store medications and biologicals on the [NAME] nursing unit. Observations revealed unattended and unlocked medication and treatment carts in the hallway, with medicated creams and other items accessible to anyone nearby, contrary to the facility's policy requiring secure storage.
The facility failed to provide preferred food items to three residents, as indicated on their meal trays. A resident with diabetes and depression did not receive pickles or diet gelatin as listed on her tray card. Another resident with diabetes, anxiety, and iron deficiency anemia reported not receiving preferred food items, including a pickle. A third resident with diabetes did not receive pickles or Lactaid milk as listed. These deficiencies show a failure to adhere to residents' care plans and meal preferences.
A facility failed to implement its antibiotic stewardship program, resulting in a resident receiving antibiotics without proper documentation. The policy required documentation of dose, duration, and indication, but a resident with multiple health conditions received 27 doses of doxycycline without a stop date or specified infection type. The DON confirmed non-compliance with the policy.
The facility did not follow its policy to offer pneumococcal vaccines to residents upon admission. Five residents lacked documentation of being offered the vaccine or having their vaccination status assessed. This was confirmed by the DON, resulting in a deficiency.
The facility failed to serve food that was palatable and at the correct temperature on one unit. Residents reported ongoing issues with cold and unpalatable food. A test tray audit confirmed that food temperatures were below the required 140°F, and observations of residents eating in their rooms supported these findings. The administrator confirmed the deficiency.
The facility consistently failed to meet the required nurse aide (NA) to resident ratios for most of January 2025. The staffing shortfall was observed across day, evening, and night shifts, with the facility not maintaining the minimum NA per resident ratios. This deficiency was confirmed by the Nursing Home Administrator.
The facility did not meet the required 3.2 hours of direct resident care per day over a 21-day period, with care hours ranging from 2.55 to 3.09 per resident. This deficiency was confirmed by the Nursing Home Administrator.
The facility failed to provide baseline care plan summaries to three residents or their representatives, as required by policy. Despite developing the care plans within the stipulated timeframe, there was no evidence that the summaries, which should include healthcare information and initial goals, were shared with the residents or their representatives.
The facility did not review care plans within seven days after comprehensive assessments for three residents. A resident with spinal stenosis, heart failure, and diabetes, and two others with heart failure, diabetes, hemiplegia, and hemiparesis, had their MDS assessments completed without documented interdisciplinary care plan meetings. The Administrator confirmed the lack of documentation.
A facility failed to implement a physician's order for a resident with spinal stenosis, heart failure, and diabetes. The resident was prescribed morphine ER, but due to unavailability, oxycodone HCl ER was ordered as a temporary replacement. The facility did not administer the oxycodone as ordered and failed to discontinue it when morphine became available, resulting in the resident receiving both medications concurrently.
A resident in hospice care, requiring assistance for bed mobility, experienced increased discomfort after staff removed a draw sheet used for repositioning, despite a physician's order and the resident's preference. The facility administrator confirmed there was no policy against using draw sheets, highlighting a failure to respect the resident's dignity and preferences.
A facility failed to investigate an injury of unknown origin for a resident with congestive heart failure and depression. Despite a policy requiring investigation of such injuries, a bruise was noted on the resident's forearm, but staff witness statements were delayed, and the resident was not interviewed. The Administrator confirmed the lack of a thorough investigation.
The facility failed to complete MDS assessments in a timely manner for seven residents. Clinical record reviews revealed that the quarterly and discharge MDS assessments were still in progress and had not been completed within the required time frames. The Administrator confirmed the delay in completing the assessments.
The facility failed to ensure physician's orders were implemented for five residents, leading to improper medication administration without required blood pressure and heart rate assessments. The Director of Nursing confirmed the deficiencies in documentation and adherence to ordered parameters.
The facility failed to store food in a sanitary manner in two resident nourishment rooms. Surveyors observed multiple unlabeled and expired food items in the freezers and refrigerators, including opened gelato, sour cream, homemade food, and various other items. The Nursing Home Administrator confirmed these items should have been removed.
The facility failed to complete accurate MDS assessments for three residents. One resident was incorrectly documented as using a chair that prevents rising, another resident's fall was not reflected, and a third resident's feeding method was inaccurately recorded. The DON confirmed these inaccuracies.
The facility failed to develop a care plan for a resident with stroke, seizures, and kidney failure, who required assistance with daily living activities and was on an antidepressant. The MDS assessment indicated the need for a care plan addressing functional ability and psychotropic drug use, but no such plan was created. The DON confirmed this oversight.
The facility failed to change a resident's PICC dressing weekly as required by policy. The resident, with diagnoses of anemia, osteomyelitis, and PTSD, reported that the dressing had not been changed in almost two weeks. Observations confirmed the dressing was dated nearly two weeks prior, and the DON acknowledged the dressing should have been changed every seven days.
The facility failed to assess and document the status of wounds for three residents as required by their policy. One resident with chronic kidney disease had no wound assessment documented after a certain date. Another resident with diabetes and heart failure had gaps in wound assessment documentation for a left heel wound. A third resident with anemia, osteomyelitis, and PTSD had no wound assessment documented after a certain date. The Nursing Home Administrator confirmed the lack of documentation.
The facility failed to develop and implement an individualized plan for a resident with PTSD. The resident experienced daily thoughts about traumatic experiences in Vietnam and had physical symptoms like shaking and hallucinations. There was no assessment or care plan addressing the resident's PTSD symptoms or triggers, and no specific interventions were in place to minimize triggers or re-traumatization.
The facility failed to ensure that the physician acknowledged the pharmacist's recommendations for two residents. For one resident, recommendations regarding the medication regimen were made but not documented as acknowledged or acted upon. For another resident, recommendations to decrease psychotropic medications were similarly unacknowledged. The Administrator confirmed that these recommendations were not addressed by the physician.
The facility failed to notify the resident's representatives in writing about the transfer and the reasons for the move for seven residents who were transferred to the hospital. The Administrator confirmed that written transfer information was not provided.
The facility failed to provide a written notice of the bed-hold policy to residents or their representatives at the time of transfer to a hospital. This deficiency was identified for six of seven sampled residents who were transferred to the hospital due to changes in their condition. The Administrator confirmed that no written notice was given upon transfer.
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.
Improper Blood Pressure Measurement on Dialysis Access Arm
Penalty
Summary
Facility staff failed to provide appropriate dialysis-related care by not adhering to policy and the resident’s care plan regarding protection of a hemodialysis access site. The facility’s policy on hemodialysis external catheter evaluation and maintenance, last reviewed February 24, 2026, directed staff to avoid taking blood pressure from an arm with a dialysis access device. The resident, who had diabetes mellitus with chronic kidney disease and required ongoing hemodialysis, had a care plan initiated November 11, 2021 and last reviewed December 17, 2025 that instructed staff to monitor the left upper extremity fistula for bleeding and to avoid using that arm for any treatment to prevent complications related to dialysis access. Despite these directives, clinical record review showed that staff documented taking the resident’s blood pressure on the left arm 10 times in January 2026, 10 times in February 2026, 14 times in March 2026, and four times in April 2026. In an interview on April 17, 2026, the Director of Nursing confirmed that the documentation showed the resident’s blood pressure had been measured on the left arm containing the dialysis access. These findings were cited under 28 Pa. Code 211.10(d) Resident care policies and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Failure to Assess and Care Plan for Resident with PTSD
Penalty
Summary
Surveyors identified that the facility failed to provide trauma-informed, person-centered care for a resident with a documented diagnosis of post-traumatic stress disorder (PTSD). The resident was admitted with PTSD, depression, polyneuropathy, and insomnia, and a Minimum Data Set assessment showed no cognitive impairment, a need for substantial assistance with activities of daily living, and a confirmed PTSD diagnosis. Despite this, the clinical record contained no documentation that the resident had been assessed for PTSD-related symptoms or triggers, and the resident’s care plan lacked any measures addressing the history of trauma, identifying triggers, or specifying interventions to minimize triggers or re-traumatization. In an interview, the Director of Nursing confirmed that the resident had not been assessed or care planned for PTSD, in violation of 28 Pa. Code 211.12(d)(3)(5) regarding nursing services.
Failure to Ensure Physician Response to Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that physicians acknowledged and addressed consultant pharmacist medication regimen recommendations for two residents, as required by policy and regulation. For Resident 6, clinical record review showed that the consultant pharmacist made recommendations regarding the medication regimen on March 20, 2026, but there was no documented evidence of the specific recommendation or that the attending physician had acknowledged or acted upon it. For Resident 12, clinical record review showed that the consultant pharmacist made recommendations regarding the medication regimen on October 20, 2025, and again on February 26, 2026, with no documented evidence of the recommendations or any physician acknowledgment or follow-up action. In an interview on April 17, 2026, at 10:22 a.m., the Director of Nursing confirmed that there was no documented evidence that the medication review recommendations made by the consultant pharmacist for Residents 6 and 12 were addressed by the physician, resulting in noncompliance with state management and nursing services regulations.
Failure to Provide Required Annual In‑Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that two nurse aides received the required 12 hours of annual in‑service training, including dementia management, resident abuse prevention, and training to address identified performance weaknesses. Review of personnel records showed that NA 1 was hired on August 28, 2023, and facility training records for the period April 17, 2025, to April 17, 2026, documented only 31 minutes of in‑service education for NA 1, limited to infection control and respirator use. Review of NA 2’s personnel record showed they were hired on December 19, 2023, and training records for the same period documented only 3 hours and 48 minutes of in‑service education for NA 2, covering safe resident handling, mechanical lift use, elopement prevention, and ethics. In an interview on April 17, 2026, at 12:59 p.m., the DON and the Nursing Home Administrator confirmed that NA 1 and NA 2 had not completed the required annual in‑service training. These findings were cited under 28 Pa. Code 201.19(7) related to personnel policies and procedures and 28 Pa. Code 201.20(a)(6)(d) related to staff development.
Failure to Report Alleged Neglect and Follow Care Plan for Dependent Resident
Penalty
Summary
The facility failed to report an alleged violation of potential neglect to the appropriate state and local authorities as required by its abuse prohibition policy. The policy, last reviewed February 24, 2025, stated that the facility prohibited abuse, mistreatment, neglect, and exploitation for all residents and required immediate reporting of incidents, investigations, and the facility's response upon receiving information concerning suspected neglect or abuse. The policy also specified that a designee was to report allegations involving neglect to the appropriate state and local authorities. There was no documented evidence that this reporting occurred for the incident involving one resident. The resident involved had diagnoses including chronic respiratory failure with hypoxia, heart failure, and venous insufficiency, had no cognitive impairment, and was dependent for ADLs such as bed mobility, transfers, and toileting. The care plan identified an ADL self-care deficit and required assistance of two to three staff and use of a bed pad for bed mobility. On review of facility documentation, a nurse aide observed a bruise on the resident's left forearm while providing care, and further investigation showed that another nurse aide had used the resident's left forearm to roll the resident toward him, resulting in a small bruise. There was no evidence that a second staff member was present or that a bed pad was used as required by the care plan, and the DON acknowledged that the facility failed to report this incident of alleged neglect to the appropriate state and local agencies.
Failure to Implement and Update Bed Mobility Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to implement and update a comprehensive care plan for a resident whose needs had changed. The resident had chronic respiratory failure with hypoxia, heart failure, and venous insufficiency, and was assessed on the Minimum Data Set as being dependent for ADLs including bed mobility, transfers, locomotion, and toileting, though able to communicate needs clearly. The care plan identified an ADL self-care deficit and directed that bed mobility be performed with assistance of two to three staff and the use of a bed pad. Facility documentation showed that during care on January 28, 2026, NA 1 observed a bruise on the resident’s left forearm. Further review revealed that NA 2 had used the resident’s left forearm to roll the resident toward him, and there was no evidence that a second staff member was present or that a bed pad was used, contrary to the existing care plan. In an interview, the resident stated she could reposition in bed with the assistance of one staff member and a bed pad, and the DON confirmed that the bed pad was not used and that the care plan did not reflect the resident’s current bed mobility status requiring assistance of one staff with a bed pad.
Failure to Serve Beverages at Required Temperature
Penalty
Summary
The facility failed to provide food and beverages at an appetizing temperature on one of five nursing units. A resident reported difficulty obtaining coffee that was not cold. Facility documentation specified that coffee should be served at a temperature greater than 140 degrees Fahrenheit at the point of service. However, during a test tray audit conducted after the last resident meal tray was served, the coffee was measured at 128 degrees Fahrenheit, which is below the required temperature. These findings were based on resident interview, review of facility documentation, and direct observation during the audit.
Failure to Store Food in a Sanitary Manner
Penalty
Summary
The facility failed to store food in a sanitary manner in the dietary department, as observed during a kitchen tour. The facility's policy, dated February 24, 2025, required staff to label food items with the date prepared or opened and discard them after seven days if opened or three days if prepared. However, during the inspection, it was found that an opened bag of shredded mozzarella and a pan of ham salad in the walk-in cooler were not discarded despite being past their labeled dates. Additionally, a pan of egg salad, a bag of lettuce, and a pan of raw pork cubes were not dated, and an opened bag of 20 sausage patties in the freezer was also not dated. The Dietary Manager confirmed that these items should have been dated and removed if expired.
Failure to Conduct Infection Surveillance
Penalty
Summary
The facility failed to perform infection surveillance in accordance with its policy. The facility's policy, titled 'Infection Control Outcome and Process Surveillance and Reporting,' last reviewed on February 24, 2025, requires the Infection Preventionist to conduct regular surveillance related to infections. However, during a review of the facility's infection control program on March 26, 2025, it was found that there was no documented evidence of any infection surveillance since January 2025. This was confirmed in an interview with the Director of Nursing, who acknowledged that infection surveillance should be conducted monthly and had not been performed as required by the facility policy since January 2025.
Failure to Employ Qualified Dietary Services Manager
Penalty
Summary
The facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. During an interview on March 23, 2025, the Dietary Manager revealed that the facility did not have a certified dietary manager. This was further confirmed by the Administrator on March 25, 2025, who acknowledged that there was no full-time dietitian employed onsite and that the facility lacked a qualified certified dietary manager to fulfill the role in the dietitian's absence. This deficiency is in violation of 28 Pa. Code 201.18(b)(3) Management.
Failure to Respond to Call Bell and Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure timely response to a call bell for a resident with chronic obstructive pulmonary disease, diabetes mellitus, and chronic pain. The resident, who had no cognitive impairment and required assistance with transfers and mobility, was observed sitting in a wheelchair with the call bell activated. Despite the facility's expectation that call bells be answered within 15 minutes, the resident reported waiting extended periods for assistance, specifically to have his urinal emptied. Additionally, the facility did not provide scheduled shower services to another resident with Parkinson's disease, depression, and anxiety. This resident, who also had no cognitive impairment, was scheduled for showers on specific days but did not receive a shower per his preference on one of those days. There was no documented evidence to confirm that the resident received the scheduled shower, indicating a failure to adhere to the care plan designed to enhance the resident's quality of life.
Failure to Support Resident's Activity Preferences
Penalty
Summary
The facility failed to ensure that a resident received care according to her preferences, which impacted her ability to attend her chosen morning activities. Resident 4, who is alert and oriented, expressed her concern that she was unable to participate in her preferred morning group activities on two consecutive days because staff did not assist her in getting up and ready in time. She preferred to be up and dressed by 7:00 a.m. to attend activities scheduled at 10:00 a.m., but staff did not assist her until after 11:00 a.m., causing her to miss these activities. The resident's clinical records indicate that she has diagnoses of congestive heart failure and osteoarthritis of the knee, and she relies on a wheelchair for mobility and staff assistance for care. Her care plan includes an intervention for staff to encourage her participation in group activities, which she enjoys and regularly attends. Despite this, the facility did not adhere to her preferences, as noted in her Minimum Data Set assessment, which emphasized the importance of her choosing her own schedule and participating in favored activities. The Director of Activities confirmed that the scheduled activities took place as planned, highlighting the facility's failure to accommodate the resident's expressed needs and preferences.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, as required by their comprehensive assessments. Resident 51, who was admitted with a diagnosis of dementia, had a Minimum Data Set (MDS) Care Area Assessment summary indicating that cognitive decline/dementia should be addressed in the care plan. However, there was no evidence of interventions for cognitive decline/dementia in the current care plan. Similarly, Resident 141, who had a diagnosis of a deep tissue injury on her right heel, had an MDS assessment noting the need to address the pressure ulcer/injury in the care plan. Yet, there was no evidence of interventions for the pressure area/injury in the current care plan. The Director of Nursing confirmed the absence of documented evidence addressing these care areas in the residents' care plans.
Failure to Implement Restorative Ambulation Program
Penalty
Summary
The facility failed to implement a restorative ambulation program for a resident as recommended by physical therapy. The resident, who had diagnoses including chronic obstructive pulmonary disease, stroke, and abnormal gait and mobility, was assessed to be alert and oriented with limited range of motion on one side of her body. The care plan indicated the need for assistance with activities of daily living due to impaired balance, and physical therapy recommended a restorative ambulation program upon discharge, noting the resident could walk 25 feet with a walker and caregiver assistance. Despite these recommendations, the resident reported not receiving the desired assistance with walking, and nursing documentation over the past 30 days showed no consistent evidence of the program being implemented. The Director of Nursing confirmed that no restorative ambulation program had been put in place as recommended. This lack of action led to the deficiency cited under 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Failure to Implement Physician's Orders and Document Care
Penalty
Summary
The facility failed to implement physician's orders for five residents, leading to deficiencies in care. Resident 37, diagnosed with heart failure, did not have daily weights recorded on multiple specified dates, despite a physician's order. Similarly, Resident 119, with chronic kidney disease and heart failure, also lacked documented daily weights on several occasions. Resident 51, who had hypertension, was administered blood pressure medication without prior blood pressure assessment as required by the physician's order. Resident 141, suffering from sepsis and a deep tissue injury, did not receive documented daily treatment for her right heel on several dates as ordered. Additionally, Resident 355, with a history of myocardial infarction and congestive heart failure, was not weighed daily as ordered on two occasions. Furthermore, this resident was observed wearing a compression stocking and wrap without a corresponding physician's order. The Director of Nursing confirmed the lack of documentation for these treatments and orders, highlighting the facility's failure to adhere to prescribed care protocols.
Failure to Apply Splint for Resident with Contracture
Penalty
Summary
The facility failed to implement necessary interventions to prevent further decline in range of motion for Resident 101, who was at risk due to a right knee contracture and muscle weakness. The resident, diagnosed with dementia and dependent on staff for personal hygiene and dressing, had a physician's order for a splint to be applied to the right lower extremity in the morning. Despite this order and the care plan indicating the need for the splint to prevent loss of range of motion, observations on multiple occasions over three days revealed that the resident was in bed without the splint applied.
Deficiencies in Catheter and Incontinence Care
Penalty
Summary
The facility failed to provide adequate catheter care for a resident with an indwelling urinary catheter. The facility's policy required catheter care to be performed twice a day and as needed, with documentation of the care provided. However, there was no documented evidence that staff provided the required catheter care for the resident, who had diagnoses including dementia and urinary retention. Observations confirmed the presence of the indwelling catheter, but the lack of documentation indicated non-compliance with the facility's policy. Additionally, the facility did not assess bladder incontinence or provide services to restore bladder function for another resident at risk for bladder function loss. The facility's policy required an incontinence assessment as part of the admission process, including a nursing assessment and a three-day bowel/bladder pattern record. Despite the resident's frequent urinary incontinence and need for assistance with toileting, there was no documented evidence of an incontinence risk assessment or a developed incontinence program. The Director of Nursing confirmed the absence of documentation for the assessment of the resident's urinary incontinence.
Medication Storage Deficiency on Nursing Unit
Penalty
Summary
The facility failed to ensure the secure storage of medications and biologicals on the [NAME] nursing unit, as observed during a survey. The facility's policy, last reviewed on February 24, 2025, mandates that medication supplies should be accessible only to authorized personnel and that medication rooms, cabinets, and supplies should remain locked when not in use. However, on March 24, 2025, from 10:30 a.m. to 11:35 a.m., a medication cart was found unattended in the hallway with two tubes of medicated creams (Permetherin) on top, accessible to anyone nearby. Additionally, from 11:55 a.m. to 12:28 p.m., a treatment cart containing medicated creams (lidocaine), wound wash cleansers, and nail clippers was also found unlocked and unattended in the hallway. The following day, on March 25, 2025, from 8:30 a.m. to 8:38 a.m., the treatment cart was again observed unlocked and unattended in the hallway, with the same contents accessible to anyone in the vicinity.
Failure to Provide Preferred Food Items to Residents
Penalty
Summary
The facility failed to ensure that residents received their preferred food items as indicated on their meal trays, affecting three residents. Resident 94, who has diabetes and depression, was noted to be alert and oriented. Her care plan included an intervention to honor her food preferences. However, during observations, she did not receive pickles with her sandwich or diet gelatin as listed on her tray card. Resident 96, with diagnoses including diabetes, anxiety, and iron deficiency anemia, also did not receive her preferred food items. She reported never receiving the food items she preferred or what was on the menu, and during an observation, her lunch tray was missing a pickle that was listed on her meal ticket. Similarly, Resident 118, who has diabetes and is alert and oriented, did not receive her preferred food items. Her care plan also included an intervention to honor her food preferences. During observations, she did not receive pickles with her sandwich or Lactaid milk as listed on her tray card. These deficiencies indicate a failure by the facility to adhere to the residents' care plans and meal preferences, as required by the regulations.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to consistently implement its antibiotic stewardship program, as evidenced by the case of a resident who was administered antibiotics without proper documentation. The facility's policy required medical providers to document antibiotic orders with dose, duration, and indication for use. Additionally, front-line nursing staff were to perform a time-out on all antibiotics upon a resident's admission, and the Consultant Pharmacist was responsible for reviewing antibiotic courses for appropriateness and monitoring provider compliance. However, these procedures were not followed for a resident who was admitted with conditions including myocardial infarction, congestive heart failure, and cellulitis. A physician's order directed the administration of doxycycline twice daily for an infection, but the order lacked a stop date and did not specify the type of infection being treated. Despite a recommendation from the pharmacist to include this information, the resident received 27 doses of the antibiotic without the necessary documentation. The Director of Nursing confirmed that the antibiotic was administered without a stop date or indication for use, indicating non-compliance with the facility's antibiotic stewardship policy.
Failure to Offer Pneumococcal Vaccines per Policy
Penalty
Summary
The facility failed to adhere to its policy regarding the offering of pneumococcal disease vaccines to residents upon admission. The policy, last reviewed on February 24, 2025, mandates that each resident be assessed for prior vaccination against pneumococcal disease and be offered the vaccine if they have not been previously vaccinated. Additionally, staff are required to document the education provided to the resident about the benefits of the vaccination, as well as whether the resident received or declined the vaccine, in the electronic medical record. Upon review, it was found that five residents (Residents 41, 51, 56, 80, and 137) did not have documented evidence in their clinical records that the facility offered them the pneumococcal vaccine or assessed their vaccination status upon admission. This lack of documentation was confirmed by the Director of Nursing during an interview. The failure to follow the established policy resulted in a deficiency as per 28 Pa. Code 211.10(d) and 28 Pa. Code 211.12(d)(1)(5).
Failure to Serve Palatable and Properly Heated Food
Penalty
Summary
The facility failed to provide food that was palatable and at an appetizing temperature on one of its nursing units. This deficiency was identified through a review of Resident Council Minutes from several months, where residents consistently reported that their food was served cold and was not palatable. During a group interview, multiple residents confirmed that hot food was frequently served cold. A test tray audit conducted revealed that the temperatures of broccoli, hashbrown, and coffee were below the required 140 degrees Fahrenheit, making them not palatable. Observations of residents eating in their rooms further confirmed that hot foods were served cold. The facility's administrator acknowledged that the food temperatures did not meet the policy guidelines.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios for 20 out of 21 days reviewed in January 2025. Specifically, the facility did not maintain the minimum staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents during the night shift. This deficiency was observed across multiple dates and shifts, indicating a consistent shortfall in staffing. The Nursing Home Administrator confirmed the failure to meet these staffing requirements during an interview conducted on February 2, 2025.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. P5520 Nurse Aide Ratio 1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the center follows staffing procedures including exhausting all possible replacements from internal staffing pool and contracted agency staff. The center continues to offer incentives, coordinate staffing schedules, and replace call offs per protocol while actively continuing to hire for all open positions and additional pool staff. 3. All registered nurses and the scheduler have been educated on the 7/01/2024 nurse aide ratio and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON/designee will audit staffing weekly x4 weeks then monthly for 2 months. Results will be reviewed by the QAPI Committee for recommendations as needed.
Facility Fails to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per day for each resident. This deficiency was identified through a review of nursing schedules over a 21-day period from January 11 to January 31, 2025. During this period, the facility consistently provided less than the required hours of care, with daily averages ranging from 2.55 to 3.09 hours per resident. The shortfall in nursing care hours was confirmed by the Nursing Home Administrator during an interview on February 1, 2025. The deficiency affected all residents in the facility, as the nursing care hours were below the mandated minimum for each day reviewed. The facility's inability to meet the required care hours suggests a systemic issue in staffing or scheduling that impacted the delivery of care to residents. The report does not provide specific details about the residents' medical conditions or the direct impact of the deficiency on their health, but it highlights a failure to comply with the established care standards.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. The Clinical Leadership Team and scheduler review the schedule daily. 2. In the event of call offs, the center follows staffing procedures including exhausting all possible replacements from internal staffing pool and contracted agency staff. The center continues to offer incentives, coordinate staffing schedules, and replace call offs per protocol while actively continuing to hire for all open positions and additional pool staff. 3. All registered nurses and the scheduler have been educated on the 7/01/2024 HPPD and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON/designee will audit staffing weekly for 4 weeks, then monthly for 2 months. Results will be reviewed by the QAPI Committee for recommendations as needed.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to ensure that a baseline care plan summary was provided to the resident or their representative for three of the six sampled residents. According to the facility's policy, a baseline care plan should be developed within 48 hours of admission and include necessary healthcare information, initial goals based on various orders, and a written summary provided to the resident or representative. However, for Residents 2, 3, and 4, there was no evidence that such summaries were provided, despite the baseline care plans being developed on specific dates. The deficiency was confirmed during an interview with the Administrator, who acknowledged the lack of evidence that the baseline care plan summaries were provided to the residents or their representatives. This failure to provide the required documentation was noted as a violation of the facility's policy and the regulatory requirement under 28 Pa. Code 201.18 (b)(1) Management.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. 1. Residents #2, 3, and 4 have been given copies of their individual care plans. 2. All new admissions will receive a summary of their baseline care plan. An audit of all new admissions in the last two weeks will be conducted to ensure that a summary of the baseline care plan was received by the resident and/or responsible party. 3. The interdisciplinary team will be re-educated on the center's Person-Centered Care Plan Policy. 4. A weekly audit for 4 weeks of all new admissions and then biweekly for 2 months of random new admissions will be conducted to verify that residents/responsible parties are given a summary of their baseline care plan. Results of the audits will be presented to the center's QAPI Committee for review and follow up actions as recommended.
Failure to Review Care Plans Timely
Penalty
Summary
The facility failed to review the care plans within seven days after the completion of the comprehensive assessment for three of six sampled residents. Resident 1, who was admitted with diagnoses including spinal stenosis, heart failure, and diabetes, had their Quarterly Minimum Data Set (MDS) assessment completed on November 3, 2024, but there was no documentation of an interdisciplinary care plan meeting. Similarly, Resident 5, with heart failure and diabetes, and Resident 6, with hemiplegia and hemiparesis, both had their Quarterly MDS assessments completed on November 20, 2024, without documented interdisciplinary care plan meetings. The Administrator confirmed the lack of documentation for these meetings during an interview on December 20, 2024.
Plan Of Correction
1. Interdisciplinary care plan meetings have been scheduled for Residents #1, 5 and 6 to review their individual care plans. 2. After completion of the resident's comprehensive and quarterly MDS, residents are to receive notification of their scheduled interdisciplinary care plan meeting to review their individual care plan. An audit of the last 2 weeks will be conducted to determine if residents/responsible parties received notification of the resident's interdisciplinary care plan meeting. 3. The interdisciplinary team will be re-educated on the center's Person Centered Care Plan Policy. 4. A weekly audit of 8 random residents for 4 weeks and then biweekly for 2 months will be conducted to verify that residents and/or responsible parties are receiving notification of the resident's scheduled interdisciplinary care plan meeting. Results of the audits will be presented to the center's QAPI Committee for review and follow up actions as recommended.
Failure to Implement Physician's Orders for Pain Management
Penalty
Summary
The facility failed to implement a physician's order for a resident with diagnoses including spinal stenosis, heart failure, and diabetes. A physician's order dated December 4, 2024, required the administration of morphine ER twice daily. However, on December 5, 2024, it was documented that the pharmacy did not have morphine available. Subsequently, on December 9, 2024, the physician ordered oxycodone HCl ER as a temporary replacement, to be discontinued upon the arrival of morphine ER. The Medication Administration Record showed that the oxycodone HCl ER was not administered as ordered on December 9, 2024, at 9:00 p.m. Furthermore, when the morphine ER was received, the staff failed to discontinue the oxycodone HCl ER, resulting in the resident receiving both medications simultaneously. In an interview on December 20, 2024, the Administrator confirmed the failure to administer the pain medication on December 9, 2024, and acknowledged that the resident continued to receive both oxycodone HCl ER and morphine ER concurrently.
Plan Of Correction
1. The Oxycodone for Resident # 1 has been discontinued. 2. Physician orders are to be implemented and followed as ordered by the physicians for all residents. An audit of new narcotic orders for the last 2 weeks will be conducted to ensure that physician orders are in place and followed as ordered by the physician. 3. The licensed nurses will be re-educated on physician orders regarding narcotic medications. 4. A weekly audit of all new narcotic orders will be conducted for 4 weeks, then a biweekly audit of new narcotic orders for 8 random residents will be conducted for 2 months to ensure that physician orders are in place and followed as ordered by the physician. Results of the audits will be presented to the center's QAPI Committee for review and follow-up actions as recommended.
Failure to Respect Resident's Dignity and Preferences
Penalty
Summary
The facility failed to respect a resident's dignity and preferences, leading to a deficiency in care. A resident, who was not cognitively impaired and required assistance for bed mobility, was admitted to hospice care with a diagnosis of congestive heart failure. The resident and a hospice nurse requested a draw sheet for repositioning due to discomfort, and a physician ordered its use. However, the draw sheet was removed by staff, citing a non-existent facility policy, resulting in increased discomfort for the resident. An observation confirmed the absence of the draw sheet, and the resident expressed a preference for its use, stating it had been used since the previous fall. The facility administrator acknowledged that there was no policy against using draw sheets, confirming the staff's error in removing it. This oversight violated the resident's right to a dignified existence and self-determination, as outlined in the facility's policies and state regulations.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one of the residents. According to the facility's Abuse Prohibition policy, injuries of unknown origin should be investigated to determine if abuse or neglect is suspected. A clinical record review showed that the resident, who had diagnoses including congestive heart failure and depression, was not cognitively impaired and required staff assistance for bed mobility. On August 16, 2024, a nurse observed a bruise on the resident's right forearm measuring 5 cm by 5 cm. However, the facility's incident investigation lacked documented evidence of obtaining staff witness statements until five days later, and there was no evidence that the resident was interviewed about the bruise. The Administrator confirmed the absence of an interview with the resident regarding her injury.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to complete Minimum Data Set (MDS) assessments in a timely manner for seven of 29 sampled residents. According to the Resident Assessment Instrument (RAI) User's Manual, significant change in status assessments, quarterly assessments, and admission assessments must be completed no later than 14 days after the Assessment Reference Date (ARD). However, clinical record reviews conducted on April 10, 2024, revealed that the MDS assessments for Residents 5, 27, 46, 90, 105, 115, and 135 were still in progress and had not been completed within the required time frames. Specifically, the quarterly MDS assessments for Residents 5, 27, 46, 90, 105, and 115 were overdue, and the discharge MDS assessment for Resident 135, who was discharged on March 14, 2024, was also incomplete. In an interview on April 12, 2024, the Administrator confirmed that the MDS assessments had not been completed within the required time frames. This failure to adhere to the mandated timelines for MDS assessments indicates a deficiency in the facility's compliance with federal requirements for resident assessments. The incomplete assessments could potentially impact the quality of care provided to the residents, as timely and accurate MDS assessments are crucial for developing appropriate care plans and ensuring residents' needs are met.
Failure to Implement Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to ensure physician's orders were implemented for five residents, leading to improper medication administration. Resident 27, diagnosed with hypertension and congestive heart failure, had medications administered without the required blood pressure and heart rate assessments. Specifically, amlodipine besylate, metoprolol succinate, and furosemide were given multiple times without documenting the necessary vital signs. Similarly, Resident 34, with a diagnosis of hypertension, received lisinopril without the required blood pressure checks. Resident 44, diagnosed with congestive heart failure and cardiomyopathy, had metoprolol succinate administered when the heart rate was below the ordered parameters. Resident 63, with hypertension and congestive heart failure, received hydralazine without proper blood pressure assessments, and Resident 76, also diagnosed with hypertension, had amlodipine besylate and lisinopril administered when the blood pressure was below the ordered parameters. The Director of Nursing confirmed that medications were administered outside the ordered parameters and that there was no documented evidence of blood pressure and heart rate assessments prior to medication administration for the mentioned residents. This failure to follow physician's orders and document necessary vital signs led to the identified deficiencies in the facility's medication administration practices.
Failure to Store Food in a Sanitary Manner
Penalty
Summary
The facility failed to store food in a sanitary manner in two of three resident nourishment rooms. In the first nourishment room, surveyors observed multiple food items in the freezer and refrigerator that were not labeled or dated, including an opened gelato container, sour cream with an expired use-by date, and various homemade food items with dates ranging from November 2023 to April 2024. Additionally, there were several opened and unlabeled items such as cheese slices, a soda cup, a water bottle, a sandwich, soup, pasta, and red grapes. These observations were made on April 11, 2024, at 10:55 a.m. In the second nourishment room, observed on April 11, 2024, at 11:17 a.m., surveyors found a water bottle in the freezer and several items in the refrigerator that were not labeled or dated, including a dish of gelatin and containers of vegetables and meat. The refrigerator door shelf was sticky, and there were multiple food items with expired use-by dates, such as chicken salad and swiss cheese, as well as various containers of food dated from February to April 2024. The Nursing Home Administrator confirmed that these food items should have been removed from the resident nourishment room refrigerators.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for three residents. For Resident 28, the MDS assessment inaccurately indicated the use of a chair that prevents rising, which was not ordered or used during the review period. Resident 63's MDS assessment did not reflect a fall that occurred in her room, despite the incident being documented in her clinical record. Resident 90, who had diagnoses including Alzheimer's, dysphagia, and protein-calorie malnutrition, was inaccurately documented as receiving Parenteral/IV feeding instead of enteral nutrition via a feeding tube as directed by the physician. The Director of Nursing confirmed the inaccuracies in the MDS assessments during an interview.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a care plan and interventions to meet the needs of a resident as identified in the comprehensive assessment. Clinical record review revealed that the resident had diagnoses including stroke, seizures, and kidney failure, and required assistance with activities of daily living and was on an antidepressant medication. The Minimum Data Set (MDS) assessment indicated that the resident's functional ability and psychotropic drug use were problem areas requiring a care plan. However, the resident's current care plan did not include interventions to address these issues. The Director of Nursing confirmed that no care plan was developed for the resident's functional ability and psychotropic drug use.
Failure to Change PICC Dressing Weekly
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality for one resident. Resident 145, who had diagnoses of anemia, osteomyelitis, and PTSD, reported that staff had not changed the peripherally inserted central catheter (PICC) dressing in almost two weeks. Observations confirmed that the PICC dressing was dated March 29, 2024, indicating it had not been changed for nearly two weeks. The facility policy required sterile dressing changes using standard aseptic non-touch technique (ANTT) at least weekly. The Director of Nursing confirmed that the PICC line dressing should have been changed every seven days.
Failure to Assess and Document Wound Status
Penalty
Summary
The facility failed to assess and document the status of wounds for three residents, as required by their policy. Resident 17, who was admitted with chronic kidney disease, had multiple wounds on the pubis and right lower quadrant. There was no documented evidence of wound assessment after March 6, 2024. Resident 46, admitted with diabetes mellitus and heart failure, had a new wound on the left heel noted on January 7, 2024. However, there was no documented evidence of wound assessment from February 27, 2024, through March 10, 2024, and from March 12, 2024, through March 28, 2024. Resident 145, admitted with anemia, osteomyelitis, and PTSD, had a sacral wound, but there was no documented evidence of wound assessment after March 21, 2024. The facility's policy, last reviewed on March 28, 2024, required weekly evaluation and documentation of wound status. The Nursing Home Administrator confirmed the lack of documented evidence for the required weekly wound assessments. This failure to adhere to the facility's policy resulted in a deficiency as per 28 Pa Code 211.10(a)(d) Resident care policies and 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized person-centered plan to provide trauma-informed care for a resident diagnosed with PTSD. Clinical record review revealed that the resident had diagnoses including anemia, osteomyelitis, and PTSD. A physician had recommended an increase in sertraline and noted that the resident was seen by a psychiatrist at the VA. The resident reported daily thoughts about traumatic experiences in Vietnam, which negatively affected him. Observations showed the resident experiencing physical shaking, hearing noises, and hallucinating, which he identified as a flashback from Vietnam. There was no assessment or care plan addressing the resident's PTSD symptoms or triggers, and no specific interventions were in place to minimize triggers or re-traumatization. The Nursing Home Administrator confirmed the lack of an assessment or care plan for the resident's PTSD symptoms or triggers.
Physician Failed to Acknowledge Pharmacist's Recommendations
Penalty
Summary
The facility failed to ensure that the physician acknowledged the pharmacist's recommendations for two residents. For Resident 63, the consultant pharmacist made recommendations regarding the medication regimen on March 4, 2024, but there was no documented evidence that the attending physician had acknowledged or acted upon these recommendations. Similarly, for Resident 115, the consultant pharmacist recommended on December 20, 2023, and March 5, 2024, that the physician consider decreasing psychotropic medications, but there was no documentation that the attending physician had acknowledged or acted upon these recommendations. The Administrator confirmed in an interview on April 12, 2024, that the medication review recommendations were not addressed by the physician.
Failure to Notify Resident Representatives of Hospital Transfers
Penalty
Summary
The facility failed to notify the resident's representatives in writing about the transfer and the reasons for the move for seven residents who were transferred to the hospital. Clinical record reviews revealed that Residents 1, 15, 17, 44, 46, 87, and 115 were transferred to the hospital after changes in their conditions. However, there was no evidence that the responsible parties of these residents were provided with written information regarding the transfers. In an interview conducted on April 12, 2024, the Administrator confirmed that the facility did not provide written transfer information, including the reasons for the move, to the residents' representatives. This deficiency was identified through clinical record reviews and staff interviews, highlighting a systemic issue in the facility's notification process for hospital transfers.
Failure to Provide Written Notice of Bed-Hold Policy
Penalty
Summary
The facility failed to provide a written notice of the bed-hold policy to residents or their representatives at the time of transfer to a hospital. This deficiency was identified for six of seven sampled residents who were transferred to the hospital due to changes in their condition. Specifically, there was no documented evidence that Residents 1, 15, 17, 46, 87, and 115, or their responsible parties or legal representatives, received written information about the facility's bed-hold policy at the time of their transfer to the hospital. During an interview on April 12, 2024, the Administrator confirmed that no written notice of the bed-hhold policy was given to the residents or their representatives upon transfer out of the facility. The clinical record reviews for the mentioned residents revealed multiple instances where the required written notice was not provided, indicating a systemic issue in the facility's process for communicating bed-hold policies during hospital transfers.
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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