Mahoning Operating Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lehighton, Pennsylvania.
- Location
- 397 Hemlock Drive, Lehighton, Pennsylvania 18235
- CMS Provider Number
- 395480
- Inspections on file
- 19
- Latest survey
- December 12, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Mahoning Operating Llc during CMS and state inspections, most recent first.
A resident with dementia, decreased mobility, and incontinence developed multiple pressure ulcers on the buttocks and sacrum despite having a care plan that included skin assessments and preventive interventions. Staff documented the resident's resistance to repositioning and the progression of wounds from open areas to deep tissue injuries and unstageable pressure injuries. The facility did not implement timely and adequate preventive measures, and detailed wound information was not provided to the resident's family prior to discharge.
The facility failed to provide proper oxygen administration and infection control for three residents. A resident had an empty humidifier bottle and undated oxygen tubing, while another had outdated nebulizer equipment. A third resident was not receiving prescribed oxygen therapy, with no physician order for discontinuation. These issues were confirmed by staff and management.
The facility failed to ensure medications were administered according to physician's parameters for two residents. One resident received Humalog injections despite low blood glucose levels, and another received Midodrine despite high blood pressure. These incidents were confirmed by the DON and Nursing Home Administrator.
The facility did not ensure the Medical Director or designee attended the quarterly QAPI meetings for two quarters. This was confirmed through sign-in sheets and an interview with the DON, revealing non-compliance with the requirement for quarterly attendance.
The facility did not send copies of written notices of facility-initiated hospital transfers to the Ombudsman for a resident transferred twice in September 2024. The social services director confirmed the lack of documentation for these and other transfers in previous months.
The facility failed to provide person-centered pain management for two residents by not consistently attempting non-pharmacological interventions before administering opioid medication and not documenting pain levels prior to administration.
The facility failed to timely report an incident of physical abuse involving two residents to the State Survey Agency. A nurse aide observed one resident hitting another in the mouth, and although the incident was reported to supervisory staff and documented, it was not reported to the State Survey Agency within the required time frames.
The facility failed to develop a comprehensive care plan for a resident with heart failure and an AICD. The care plan lacked necessary checks, monitoring for complications, and emergency procedures for the AICD device. This deficiency was confirmed through a clinical record review and staff interview.
The facility failed to develop and implement individualized plans to manage a resident's dementia-related behavioral symptoms, compromising the resident's safety and well-being. Despite documented behavioral issues such as incessantly calling out, yelling, and physical aggression, the resident's care plan did not address these behaviors or include individualized non-pharmacological approaches, purposeful activities, or environmental modifications.
The facility failed to provide written notice of facility-initiated transfers to the hospital for four residents. Clinical record reviews and staff interviews revealed that the required written notices, including the reason for the transfer and contact information for the Ombudsman, were not provided. The Nursing Home Administrator confirmed the absence of these notifications.
Failure to Prevent and Manage Pressure Ulcers in High-Risk Resident
Penalty
Summary
The facility failed to consistently provide care and services in accordance with professional standards to prevent the development of pressure ulcers for one resident. The resident, who had multiple risk factors including dementia, decreased mobility, incontinence, and a history of falls, was identified as being at risk for impaired skin integrity. The care plan included interventions such as regular skin assessments, keeping the skin clean and dry, applying protective creams, and using a mechanical lift for transfers. Despite these interventions, the resident developed multiple open and discolored areas on the buttocks and sacrum, which were identified by staff during routine care. Clinical documentation and staff witness statements revealed that the resident was resistive to repositioning and required significant assistance with activities of daily living. Initial assessment found a new open area on the left inner gluteal fold, followed by the discovery of additional open and non-blanchable areas on the buttocks and sacrum. The wounds progressed to deep tissue injuries and unstageable pressure injuries, with the presence of slough and eschar. The facility's investigative reports and nursing notes documented the progression of these wounds and the resident's combative behavior during care, which further complicated wound management. Although the care plan addressed the resident's risk factors, the facility did not implement timely and adequate preventive measures to prevent the development of pressure ulcers. The documentation also indicated that detailed wound descriptions and measurements were not provided to the resident's wife prior to discharge. Interviews with the DON and NHA confirmed the failure to prevent the development of pressure ulcers in this resident, as required by professional standards and regulatory requirements.
Deficiency in Oxygen Administration and Infection Control
Penalty
Summary
The facility failed to provide supplemental oxygen administration care consistent with professional standards of practice for three residents. For Resident 2, the humidifier bottle was found empty, and the oxygen tubing was not dated as per facility policy. Resident 16 had nebulizer tubing and a mask that had not been replaced for over 25 days, exceeding the recommended timeframe. These observations were confirmed by a licensed practical nurse. Resident 82 was observed with the oxygen concentrator on, but the nasal cannula was not applied to the resident and was instead placed in a clear bag. The oxygen tubing was also not dated. An interview with a licensed practical nurse revealed that the resident was being evaluated for discontinuation of oxygen therapy, but there was no physician order to withhold oxygen therapy. The nursing home administrator and the Director of Nursing confirmed that the nursing staff failed to adhere to facility policies concerning oxygen administration and infection control practices, and that Resident 82 was not receiving oxygen as prescribed.
Failure to Administer Medications According to Physician's Parameters
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards by not ensuring that licensed nurses accurately administered prescribed medication according to physician's parameters for two residents. Resident 75, who had diagnoses including diabetes and chronic kidney disease, received Humalog injections outside the prescribed parameters on two occasions. The medication was administered despite blood glucose levels being below the threshold specified by the physician's order. This was confirmed by the Director of Nursing during an interview. Resident 11, diagnosed with Parkinson's disease, benign prostatic hyperplasia, and a history of COVID-19, was also affected by improper medication administration. The resident received Midodrine for hypotension despite having a systolic blood pressure exceeding the physician-ordered threshold. This incident was confirmed by both the Nursing Home Administrator and the Director of Nursing. The facility's failure to adhere to professional standards of nursing care resulted in medications being administered contrary to specific physician-ordered parameters.
Medical Director's Absence at QAPI Meetings
Penalty
Summary
The facility failed to ensure the Medical Director or their designee attended the quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for two out of four quarters, specifically in April 2024 and January 2025. This deficiency was identified through a review of the QAPI Committee meeting sign-in sheets, which showed the absence of the Medical Director or designee at the meetings held on April 25, 2024, and January 30, 2025. An interview with the Director of Nursing on February 21, 2025, confirmed the absence of the Medical Director or designee at these meetings, indicating a failure to meet the regulatory requirement for quarterly attendance.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide copies of written notices of facility-initiated hospital transfers to a representative of the Office of the State Long-Term Care Ombudsman for one resident. Specifically, Resident 56 was transferred to the hospital on two occasions in September 2024, and although written notices were provided to the resident and their representative, there was no documented evidence that these notices were sent to the Ombudsman. An interview with the social services director confirmed the absence of documentation for these transfers and additional facility-initiated transfers in previous months, including April, June, July, and September 2024.
Failure to Provide Person-Centered Pain Management
Penalty
Summary
The facility failed to provide person-centered pain management consistent with professional standards of practice for two residents. Resident 43, who was admitted with cervical and intervertebral disc disorders, experienced almost constant pain as indicated in the MDS assessment. Despite having a care plan that included non-pharmacological interventions, the facility did not consistently attempt these methods before administering oxycodone. The MAR for March 2024 showed that Resident 43 received oxycodone 18 times without documentation of pain levels prior to administration, and the resident confirmed that non-pharmacological interventions were not offered consistently. Similarly, Resident 8, admitted with pyogenic arthritis and spondylosis, had a physician's order for oxycodone for severe pain. The MAR for February and March 2024 revealed that the resident received the medication 48 times in February and 12 times in March, with non-pharmacological interventions not attempted prior to administration in almost all instances. Interviews with the DON and NHA confirmed the lack of consistent non-pharmacological interventions and pain level assessments before administering pain medication.
Failure to Timely Report Resident Abuse
Penalty
Summary
The facility failed to timely report an incident of physical abuse involving two residents to the State Survey Agency. According to the facility's abuse prohibition policy, staff are required to report any allegations of abuse immediately to their supervisor, and the facility administrator or designee is responsible for follow-up investigation and reporting to the required agencies within five days. However, the facility did not adhere to this policy when a nurse aide observed one resident hitting another resident in the mouth with the back of her hand. The incident was reported to supervisory staff, but the facility did not report the abuse to the State Survey Agency within the required time frames. The incident involved Resident 4 hitting Resident 5 in the mouth after holding her wrist and telling her to shut up. Resident 5 was assessed and found to have no skin impairments, open areas, bruising, swelling, or dental issues. Despite the immediate reporting to supervisory staff and documentation in progress notes, the Nursing Home Administrator and Director of Nursing confirmed that the physical abuse was not reported to the State Survey Agency as required by the facility's policy and state regulations.
Failure to Develop Comprehensive Care Plan for Resident with AICD
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan to meet the individualized needs of a resident with heart failure and an automatic implantable cardiac defibrillator (AICD). The resident's care plan did not include necessary checks or monitoring for signs and symptoms of AICD complications, nor did it outline emergency care procedures for the AICD device. This deficiency was identified during a survey ending on March 22, 2024, and confirmed through a review of the resident's clinical record and an interview with the MDS Coordinator. The resident, who was admitted to the facility with diagnoses including heart failure and the presence of an AICD, had a cardiology progress note indicating the need to ensure the move to the skilled nursing facility did not affect the AICD device. Despite this, the care plan lacked specific actions to be taken if the AICD was activated, such as consulting the physician, obtaining vital signs, and ensuring the safety of the resident and staff. The deficiency was confirmed by Employee 1, the RN and MDS Coordinator, who acknowledged the failure to fully address the care and management of the resident's AICD in the care plan.
Failure to Address Dementia-Related Behaviors
Penalty
Summary
The facility failed to develop and implement individualized plans to manage a resident's dementia-related behavioral symptoms, compromising the resident's safety and well-being. Resident 4, diagnosed with Alzheimer's disease and exhibiting severe cognitive impairment, displayed numerous behavioral issues such as incessantly calling out, yelling, entering other residents' rooms, and physical aggression. Despite these behaviors being documented in nursing progress notes over several months, the resident's care plan did not address these specific behaviors, nor did it include individualized interdisciplinary non-pharmacological approaches to care, purposeful activities, or environmental modifications tailored to the resident's needs. The facility did not provide evidence of specialized services and supports for Resident 4, such as specialized activities, nutrition, and environmental modifications, based on the resident's abilities and dementia-related behaviors. During an interview, the Nursing Home Administrator and Director of Nursing confirmed the lack of an individualized, person-centered care plan for Resident 4's dementia care and behaviors. This failure to provide necessary care and services was a significant deficiency identified during the survey.
Failure to Provide Written Notice of Transfer
Penalty
Summary
The facility failed to ensure that a written notice of facility-initiated transfer to the hospital was provided to the resident and resident's representative for four residents. Specifically, Residents 47, 8, 18, and 39 were transferred to the hospital on various dates, but there was no evidence that written notices containing all required contents were provided. These contents include the reason for the transfer, the effective date of the transfer, the location to which the resident was transferred, contact and address information for the Office of the State Long-Term Care Ombudsman, and, if applicable, information for the agency responsible for the protection and advocacy of individuals with developmental disabilities. An interview with the Nursing Home Administrator confirmed that there was no evidence of written notifications being provided to the residents and their representatives for these facility-initiated transfers. This deficiency was identified through clinical record reviews and staff interviews, which revealed the absence of the required written notices for the transfers of Residents 47, 8, 18, and 39.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
