Meadowview Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in White Marsh, Pennsylvania.
- Location
- 9209 Ridge Pike, White Marsh, Pennsylvania 19128
- CMS Provider Number
- 395296
- Inspections on file
- 29
- Latest survey
- October 22, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Meadowview Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including malnutrition and dementia, experienced ongoing poor oral intake and refusal of nutritional supplements. Despite documented low food and fluid intake over an extended period, staff did not notify the dietitian for reassessment or implement effective interventions. The resident developed abnormal blood values and was hospitalized for dehydration and electrolyte imbalance.
A resident with PTSD had a care plan specifying that male aides should not provide care due to past trauma triggers, as requested by the resident and their family. Despite this, a male aide was assigned to the resident, resulting in allegations of abuse. Both the aide and the resident confirmed awareness of the restriction, indicating the facility did not follow the established care plan.
A resident with a history of atherosclerotic heart disease reported being pushed by an aide and was observed with a large hematoma on the forehead, but facility documentation inaccurately stated the skin was intact with no discoloration. A registered nurse confirmed the injury, revealing a discrepancy in the resident's medical record.
A resident with multiple cardiac and hematologic conditions had a documented DNR order in both the POLST form and physician orders. Despite this, nursing staff initiated a Code Blue, performed CPR, and administered epinephrine when the resident was found unresponsive, actions confirmed by the DON to be contrary to the resident's code status.
The facility did not meet the required nurse aide staffing levels from November 10 to November 30, 2024. During this period, the facility failed to provide the mandated number of nurse aides per residents across all shifts. The day shift lacked sufficient staffing on multiple dates, while the evening shift was understaffed throughout the entire period. The night shift also experienced staffing shortages on several dates. These deficiencies were confirmed through a review of facility data and an interview with the Nursing Home Administrator and Staffing Coordinator.
The facility failed to meet the required LPN staffing levels across all shifts over a three-week period. Specifically, the facility did not provide the minimum of 1 LPN per 25 residents during the day shift, 1 LPN per 30 residents during the evening shift, and 1 LPN per 40 residents on the night shift. These deficiencies were confirmed through a review of the facility's census data, nursing schedules, and staff punch reports, as well as an interview with the Nursing Home Administrator and Staffing Coordinator.
The facility did not meet the required 3.2 PPD hours of direct resident care for 19 out of 21 days reviewed. Nursing schedules and staff punch reports showed care hours ranging from 2.87 to 3.18, falling short of the mandated hours. Interviews with the Nursing Home Administrator and Staffing Coordinator confirmed the deficiency.
The facility failed to maintain a clean and safe environment in units A, B, and E, with issues such as unsanitary conditions, improper storage in shower rooms, and maintenance problems. Observations included CPAP tubing on the floor, dried substances, strong odors, and stained toilets. Interviews with residents and staff confirmed these deficiencies, highlighting the need for improved cleaning and maintenance practices.
The facility failed to implement Enhanced Barrier Precautions for residents with indwelling medical devices, such as gastrostomy tubes, as required by their policy. Additionally, staff did not adhere to proper hand hygiene protocols during medication administration, as observed with two employees who failed to sanitize their hands between residents.
The facility did not maintain an effective antibiotic stewardship program, failing to review antibiotic usage for appropriateness for 73 residents over several months. The Infection Preventionist did not conduct required reviews, leading to a deficiency under state regulations.
A resident's oxycodone medication was misappropriated due to the facility's failure to adhere to narcotic management policies. The resident, with multiple health conditions, required pain management, but discrepancies in medication counts were discovered. Staff failed to conduct proper narcotic counts and document medication administration, leading to missing tablets and altered records.
A resident rushed into the dining room, took food from another's tray, and began choking after slipping and falling. The facility failed to conduct a thorough investigation, as required by policy, due to incomplete staff interviews and missing documentation.
Two residents at an LTC facility had their PASRR Level 1 assessments inaccurately completed, failing to list serious mental illnesses despite their medical records indicating conditions such as bipolar disorder and schizophrenia. The Director of Social Work confirmed the inaccuracies, highlighting a lapse in the facility's adherence to PASRR requirements.
A facility failed to create a baseline care plan for a resident with a history of opioid abuse, psychoactive substance abuse, and schizophrenia. The care plan lacked sections on mental health, social service needs, and behavioral concerns. The Assistant DON confirmed the absence of a developed care plan and interventions for the resident's drug abuse issues.
The facility failed to implement comprehensive care plans for two residents. One resident, with multiple diagnoses, was at risk for aspiration and was observed using a straw against recommendations, leading to coughing. Another resident, with severe cognitive impairment, required 1:1 supervision during meals but was left unsupervised, resulting in choking and hospitalization for aspiration pneumonia. The Nursing Home Administrator could not recall details of the incidents.
A non-physician practitioner at an LTC facility ordered an incorrect dosage of Ozempic for a resident with multiple health conditions, including diabetes. The practitioner mistakenly prescribed a 2 mg dose, contrary to the manufacturer's guidelines, which recommend starting at 0.25 mg. The resident experienced pain and nausea following the administration of the incorrect dose.
The facility failed to follow physician orders for insulin administration for two residents and adaptive equipment for another. One resident's elevated blood sugar levels were not reported to the physician, and another resident's insulin was not administered without explanation. Additionally, a resident was observed using a straw against physician orders, with no comprehensive care plan documented for their swallowing difficulties.
The facility failed to prevent pressure ulcers in two residents with cognitive deficits and malnutrition. Despite orders to offload heels, observations showed improper positioning and lack of offloading measures, confirmed by staff interviews. One resident reported heel pain, and heel boots were found misplaced, indicating non-compliance with pressure ulcer prevention policies.
A resident with limited range of motion was observed with their head tilted and unsupported in a Geri-chair, lacking necessary positioning devices. The care plan did not include interventions for head/neck positioning, and the Rehab director confirmed the absence of such measures despite the resident's neck contracture.
A discrepancy in the accounting of lorazepam liquid medication was identified in the B unit medication room. An LPN observed that the bottle contained 14 ml, while the narcotic count sheet indicated only 4.5 ml should remain. This discrepancy was noted two days earlier, with nearly 10 ml more than accounted for. The DON confirmed the issue.
A facility failed to monitor a resident's antipsychotic medication, Quetiapine Fumarate, for adverse effects as recommended by a pharmacy consultant. Despite a care plan intervention to monitor the medication's effectiveness and tolerance, there was no evidence of consistent monitoring for potential side effects such as ataxia, falls, and other serious conditions. The Assistant Director of Nursing confirmed the lack of monitoring, resulting in a deficiency in care.
The facility failed to provide accurate meal trays and honor food preferences for several residents. A resident did not receive their requested double meat sandwich, and others reported missing items like French fries and canned fruit. Staff confirmed these deficiencies, indicating a failure to adhere to the facility's policy on accommodating food preferences.
The facility failed to provide 1:1 supervision for two residents with suicidal ideations. One resident, with moderate cognitive impairment and depression, was left unattended in a hospital triage area, allowing them to leave unsupervised. Another resident, with anxiety, schizophrenia, and depression, was found alone in their room without the required supervision, despite being on 1:1 supervision for behaviors.
A resident with severe cognitive impairment was verbally, physically, and psychologically abused by a nurse aide, resulting in injuries and signs of fear. The abuse was witnessed by another staff member and confirmed by video footage. The facility's policies on abuse prevention and dementia care were not followed.
A resident with severe cognitive impairment was subjected to physical and verbal abuse by a nurse aide, resulting in immediate jeopardy. The NHA and DON failed to manage the facility effectively, leading to the resident being forcefully pushed and punched, causing injury and pain.
Failure to Ensure Adequate Nutrition and Hydration Resulting in Hospitalization
Penalty
Summary
Facility staff failed to adequately assess, monitor, and implement interventions to ensure that a resident's nutritional and hydration needs were met. The facility's own policy required staff to recognize and address each resident's nutritional and hydration needs, including regular assessments by a registered dietitian and daily documentation of intake by nursing staff. However, the registered dietitian was not notified of a dietary consult requested by the nurse practitioner after the resident was noted to have poor oral intake and refusal of nutritional supplements. The last nutritional assessment by the dietitian had been completed over a month prior to the incident, and no updated assessment or intervention was implemented in response to the resident's ongoing poor intake. The resident in question had multiple diagnoses, including coronary artery disease, dementia, COPD, and malnutrition, and was identified as being at risk for malnutrition and dehydration. Physician orders were in place for nutritional supplements, but nursing documentation showed repeated refusals of both meals and supplements over a two-week period. Fluid intake records indicated the resident consistently consumed significantly less than the required daily fluid needs, with intake often less than half of the minimum requirement. Despite these ongoing issues, there was no evidence of effective intervention or escalation to address the resident's declining intake. Laboratory results eventually revealed critically abnormal blood values, including elevated sodium, chloride, and BUN, indicating dehydration and electrolyte imbalance. Nursing staff notified the nurse practitioner, who ordered intravenous fluids, but attempts to administer them were unsuccessful due to the resident's resistance. The resident was subsequently transferred to the hospital, where they were admitted with diagnoses of hypernatremia and dehydration. The facility's failure to assess, monitor, and intervene resulted in actual harm to the resident.
Failure to Follow Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to follow a resident's care plan regarding the assignment of caregivers, specifically for a resident with a diagnosis of post-traumatic stress disorder (PTSD) whose care plan indicated that male caregivers were a trigger due to past traumatic events. The care plan, dated September 23, 2023, and supported by the resident's sister's request, specified that the resident should not receive care from male aides. Despite this, documentation showed that on May 1, 2025, a male aide was assigned to the resident, leading the resident to make allegations of abuse. Interviews with both the assigned aide and the resident confirmed that the aide was aware of the restriction and that the resident did not want male aides to assist with care. This deficiency was identified during a review of 15 resident records, with the facility failing to ensure the care plan was followed as required by resident care policies and nursing services regulations. The deficiency centers on the facility's inaction in adhering to the individualized care plan and respecting the resident's mental and psychosocial needs, as documented and communicated by both the resident and their family.
Failure to Accurately Document Resident Injury in Medical Records
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards for one resident. A review of the clinical records for a resident who was alert, oriented, and diagnosed with atherosclerotic heart disease revealed inconsistencies in documentation following an incident. The nursing note indicated that the resident reported being pushed by an aide while being put to bed and was observed with a large hematoma on the forehead, for which an icepack was applied. However, facility documentation stated that the resident's skin was intact with no discoloration. An interview with the unit supervisor and registered nurse who assessed the resident immediately after the incident confirmed the presence of the forehead injury, highlighting the discrepancy in the medical record.
Failure to Honor DNR Order for Resident
Penalty
Summary
The facility failed to follow physician orders regarding a resident's code status. The resident, who had diagnoses including combined systolic and diastolic heart failure, pericardial effusion, pleural effusion, and thrombocytopenia, was admitted with a documented Do Not Resuscitate (DNR) order as indicated on both the Pennsylvania Orders for Life Sustaining Treatment (POLST) form and a physician order in the electronic clinical record. Despite these clear directives, when the resident was found unresponsive with slow, shallow breathing and low oxygen saturation, nursing staff initiated a Code Blue, called 911, and performed CPR, including administering multiple rounds of epinephrine. The nursing progress note detailed that the resident was given oxygen and that CPR was started by staff until paramedics arrived, contrary to the DNR order. The Director of Nursing confirmed during an interview that the facility did not implement the physician's DNR order for this resident. This failure to honor the resident's documented code status constituted a deficiency in following physician orders and respecting the resident's end-of-life preferences.
Facility Fails to Meet Nurse Aide Staffing Requirements
Penalty
Summary
The facility failed to meet the required nurse aide staffing levels as mandated by the regulation effective July 1, 2024. During the review period from November 10, 2024, to November 30, 2024, the facility did not provide the minimum required number of nurse aides per residents across all shifts. Specifically, the facility did not maintain one nurse aide per 10 residents during the day shift on multiple dates, including November 12, 14, 15, 20, 21, 22, 23, 27, 29, and 30. Similarly, the evening shift was understaffed on all dates from November 10 to November 29, failing to provide one nurse aide per 11 residents. The night shift also experienced staffing shortages on several dates, including November 10, 11, 14, 18, 23, 25, 26, 28, and 30, where the facility did not provide one nurse aide per 15 residents. These deficiencies were confirmed through a review of facility census data, nursing schedules, and staff punch reports, as well as an interview with the Nursing Home Administrator and Staffing Coordinator.
Plan Of Correction
5520 The Provider submits the following plan of correction in good faith and to comply with federal regulations. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. The facility cannot go back retroactively to correct this issue. 2. The NHA, DON, and staffing coordinator were educated by the regional nurse on the nursing assistant staffing ratios for dayshift, evening shift, and nightshift. 3. The NHA/designee will audit staffing ratios daily as well as projected ratios for the upcoming shifts using the PA FOH staffing grid to ensure the required nursing assistant ratios are met. 4. Results of audits will be submitted to the quality assurance committee to determine if further action is needed.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) across all shifts over a three-week period from November 10, 2024, to November 30, 2024. Specifically, the facility did not provide the minimum of 1 LPN per 25 residents during the day shift on November 12, 13, and 16, 2024. Additionally, the evening shift was understaffed with less than 1 LPN per 30 residents on November 11, 26, and 30, 2024. The night shift also fell short of the required 1 LPN per 40 residents on November 15 and 19, 2024. These deficiencies were confirmed through a review of the facility's census data, nursing schedules, and staff punch reports, as well as an interview with the Nursing Home Administrator and Staffing Coordinator on December 5, 2024.
Plan Of Correction
The Provider submits the following plan of correction in good faith and to comply with federal regulations. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. The facility cannot go back retroactively to correct this issue. 2. The NHA, DON, and staffing coordinator were educated by the regional nurse on the LPN staffing ratios for dayshift, evening shift, and nightshift. 3. The NHA/designee will audit staffing ratios daily as well as projected ratios for the upcoming shifts using the PA DOH staffing grid to ensure the required LPN ratios are met. 4. Results of audits will be submitted to the quality assurance committee to determine if further action is 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 patient daily (PPD) for 19 out of 21 days reviewed. This deficiency was identified through a review of the facility's census data, nursing schedules, and staff punch reports over a three-week period. The specific days where the facility did not meet the required hours of care ranged from providing 2.87 to 3.18 hours of care, falling short of the mandated 3.2 hours on most days. Interviews conducted on December 5, 2024, with the Nursing Home Administrator and the Staffing Coordinator confirmed the shortfall in nursing hours provided. The facility's inability to consistently meet the required staffing levels indicates a systemic issue in maintaining adequate nursing care hours, impacting the overall care provided to residents during the specified period.
Plan Of Correction
The Provider submits the following plan of correction in good faith and to comply with federal regulations. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. The facility cannot go back retroactively to correct this issue. 2. The NHA, DON, and staffing coordinator were educated by the regional nurse on the state required PPD of 3.20 per patient day. 3. The NHA/designee will audit the daily PPD as well as the projected PPD for the upcoming day using the PA DOH grid to ensure the required PPD has been met. 4. Results of audits will be submitted to the quality assurance committee to determine if further action is needed.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment across three of its five nursing units, specifically units A, B, and E. Observations on the B nursing unit revealed several issues, including CPAP tubing on the floor in room B 101, a dried brown substance identified as tube feeding on the floor of room B 106, and a strong urine odor in room B 118, which also lacked bed sheets and had debris on the floor. Room B 113 contained two oxygen concentrators, food particles, and an open hamper with dirty clothes. Interviews with staff confirmed these observations, with a housekeeper noting difficulty in removing the dried substance and the housekeeping director acknowledging the need for chemical cleaning. Further issues were identified in the E unit shower room, which was being used as storage, leaving only one shower stall available for use. The room contained resident trays, clothing, wheelchair parts, and hygiene supplies exposed to steam. Interviews with residents revealed additional concerns, such as stained toilets, a lack of necessary bathroom safety equipment, and maintenance issues like flickering lights and cracked ceilings. The regional maintenance director confirmed the presence of stains in multiple rooms, attributing them to hard water and indicating the need for specific cleaning supplies to address the issue.
Inadequate Infection Control and Hand Hygiene Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Specifically, Resident R129, who was admitted with a gastrostomy due to dysphagia, did not have EBP implemented, as confirmed by the Unit Manager. Similarly, Resident R21, who also had a gastrostomy tube and was receiving artificial nutrition, was observed without any EBP in place. The facility's policy on Transmission Based Precautions, revised in April 2024, mandates the use of EBP for residents with wounds or indwelling medical devices, regardless of known infection or colonization with multidrug-resistant organisms (MDRO). However, there was no documentation available to indicate that EBP was implemented for Resident R21. Additionally, the facility's staff failed to adhere to proper hand hygiene protocols during medication administration. Observations revealed that Employee E22 and Employee E25 did not sanitize or wash their hands between administering medications to different residents. This was contrary to the facility's Medication Administration and Disposition policy, which requires staff to follow established infection control procedures, including hand hygiene. Employee E25 was instructed by the unit manager to sanitize her hands after failing to do so, and she confirmed the lapse in proper infection control practice.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program, as evidenced by the lack of a system to monitor antibiotic usage effectively for three out of four months reviewed. The facility's policy required that all clinical infections treated with antibiotics undergo review by the Infection Preventionist (IP) or designee, and that all antibiotic starts be reviewed within 48 hours to determine if continued therapy was justified. However, documentation from January to April 2024 revealed that the facility did not complete reviews of antibiotic usage for appropriateness or adherence to usage criteria for the antibiotics prescribed, affecting 73 residents. An interview with the Infection Control Nurse confirmed that the reviews were not conducted according to the facility's antibiotic stewardship program. The facility's policy outlined specific criteria for justified antibiotic use and interventions for unjustified therapy, but these were not followed. The lack of adherence to the policy resulted in a deficiency under 28 Pa. Code 211.10(d) Resident care policies and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Failure to Protect Resident from Medication Misappropriation
Penalty
Summary
The facility failed to protect a resident from misappropriation of medication, specifically oxycodone, which was not properly accounted for. The facility's policies on abuse prevention and narcotic management were not adhered to, leading to a discrepancy in the medication count for a resident identified as R205. The resident, who had diagnoses including heart failure, renal failure, and respiratory failure, required pain management and had an order for oxycodone to be administered as needed. However, there were no documented doses of oxycodone administered on December 24, 2023, and discrepancies were noted in the medication count on subsequent days. The facility's narcotic management policy required that controlled medications be counted by two professional nurses at the beginning and end of each shift, with any discrepancies immediately reported to the Director of Nursing. However, on December 24 and 25, 2023, there were no signatures from nurses for shift changes, indicating a failure to conduct proper narcotic counts. A licensed nurse discovered a discrepancy on December 26, 2023, when the narcotic count showed 29 tablets missing. The facility's documentation revealed that the narcotic sign-out page was altered without proper documentation or explanation, and the missing tablets were not accounted for. Interviews with staff members involved revealed inconsistencies in their accounts of the narcotic count process and handling of the medication keys. One nurse admitted to not counting the narcotics with the incoming nurse, while another nurse reported issues with documenting medication administration due to technical problems with the electronic medical record system. The Nursing Home Administrator confirmed that the licensed nurses did not follow proper protocols regarding shift counts, narcotic inventory logs, and medication administration documentation, leading to the misappropriation of the resident's medication.
Incomplete Investigation of Resident Incident
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an alleged violation involving Resident R81. The incident occurred when the resident, who was in his room, rushed into the dining room at mealtime and began taking food from another resident's tray, which was not part of his diet. Despite staff instructions to stop and slow down, the resident continued to shove food into his mouth. As staff attempted to approach him, the resident stood up, slipped on food he had dropped, and fell into a table, hitting his head and subsequently falling to the floor. The nursing staff present in the dining room responded to the situation, observing the resident turning cyanotic. An RN performed an abdominal thrust, causing the resident to vomit the food in his mouth. The resident vomited again, and 911 was called. The resident was assessed with a head laceration and was transferred to the hospital, where he was diagnosed with aspiration pneumonia. The investigation into the incident was incomplete, as the facility did not obtain further statements or conduct interviews with other staff present during the dinner when the incident occurred. The Nursing Home Administrator was unable to provide additional documents related to the investigation, citing that most of the staff involved were agency nurses who no longer worked at the facility. This lack of thorough investigation and documentation was a violation of the facility's policy on reporting and investigating incidents of resident abuse, neglect, or injury of unknown sources.
Inaccurate PASRR Assessments for Residents with Mental Illnesses
Penalty
Summary
The deficiency identified in the report pertains to the improper completion of PASRR (Preadmission Screening and Resident Review) assessments for two residents, R25 and R208, at a nursing facility. The PASRR process, established by the Omnibus Budget Reconciliation Act (OBRA) of 1987, aims to identify individuals with mental illness or intellectual disabilities, ensure appropriate placement, and guarantee necessary services. The facility's policy mandates that Social Services are responsible for the Level 1 screening process, which must be completed by the day of admission. However, the PASRR Level 1 assessments for both residents failed to accurately reflect their serious mental illnesses, despite their medical records indicating diagnoses such as bipolar disorder, psychotic disorder, and schizophrenia. The report details that Resident R25's PASRR Level 1 assessment, dated August 31, 2023, did not list any serious mental illnesses, even though the resident's Admission MDS indicated diagnoses of bipolar disorder and psychotic disorder. Similarly, Resident R208's PASRR Level 1 assessment, dated February 29, 2024, also failed to list any serious mental illnesses, despite the resident's Admission MDS showing a diagnosis of schizophrenia. The Director of Social Work, Employee E10, confirmed during an interview that the assessments were not completed accurately and should have included the residents' serious mental illnesses. This oversight indicates a failure in the facility's adherence to the PASRR process, as outlined in their policies and the regulatory requirements.
Failure to Develop Baseline Care Plan for Resident with Drug Abuse History
Penalty
Summary
The facility failed to develop a baseline care plan for a newly admitted resident with a history of drug abuse. The resident, identified as having opioid abuse, psychoactive substance abuse, and schizophrenia, was admitted with these diagnoses. A physician's progress note confirmed the resident's history of opioid (heroin) abuse. Although a baseline care plan dated March 4, 2024, was reviewed, it lacked completed sections addressing the resident's mental health needs, social service needs, behavioral concerns, and social service goals. An interview with the Assistant Director of Nursing confirmed the absence of a developed baseline care plan and implemented interventions for the resident's drug abuse concerns.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident R40, who had multiple diagnoses including Type 2 diabetes, obesity, and schizoaffective disorder. The resident was assessed by a speech therapist who recommended no straws for thin liquids due to the risk of aspiration. Despite this recommendation and a physician's order, the care plan did not reflect these needs, and the resident was observed coughing while drinking orange juice with a straw. This incident was confirmed by the unit manager and the speech therapist, who removed the straw from the resident. For Resident R81, the facility did not implement the care plan interventions related to mealtime behaviors and safety. The resident, diagnosed with anxiety, depression, schizophrenia, and severe cognitive impairment, was on a pureed diet and required 1:1 supervision during meals. The care plan included interventions to prevent the resident from stealing food and to ensure safe eating practices. However, during an incident in the dining room, the resident began eating food from other residents' trays and consumed his own meal rapidly without swallowing, leading to choking and a fall. The resident was subsequently hospitalized with aspiration pneumonia. The Nursing Home Administrator was unable to recall the details of the incident involving Resident R81, and the nurse involved was no longer employed at the facility. The administrator stated that the care plan interventions were intended for mealtime, but the resident's behaviors prevented proper feeding by the nurse. These deficiencies highlight the facility's failure to ensure comprehensive and effective care planning and implementation for residents with specific needs.
Improper Medication Dosage for Resident
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards of practice for a resident receiving an antidiabetic medication. A non-physician practitioner, identified as Employee E 18, ordered an incorrect dosage of Ozempic for a resident with a history of bipolar disorder, osteoarthritis, cognitive communication deficit, peripheral vascular disease, left leg above knee amputation, hypertension, anxiety, and major depression. The resident's clinical record indicated a blood sugar level of 260, with morning labs showing a blood sugar level of 350, and an A1c of 6.4. Despite these indicators, the practitioner ordered a 2 mg dose of Ozempic, which was not in line with the manufacturer's recommended starting dose of 0.25 mg once weekly. The error was confirmed during an interview with Employee E 18, who acknowledged mistakenly ordering the wrong dose. The resident received the first dose of 2 mg on May 16, 2024, and subsequently experienced pain during administration and nausea the following day. The manufacturer's instructions for Ozempic specify a gradual increase in dosage, starting at 0.25 mg and only reaching 2 mg after at least four weeks on a 1 mg dose. This oversight in following the prescribed dosage guidelines led to the deficiency noted in the facility's care standards.
Failure to Follow Physician Orders for Insulin and Adaptive Equipment
Penalty
Summary
The facility failed to follow physician orders for insulin administration for two residents and adaptive equipment for another resident. Resident R6, who has diabetes, had physician orders for insulin administration and notification if blood sugar levels exceeded 400 mg/dL. However, on two occasions, the resident's blood sugar levels were above this threshold, and there was no documentation indicating that the physician was notified. Similarly, Resident R42, who is at risk for complications due to non-compliance with diabetes management, had an order for Levemir insulin that was not administered on a specific date, with no documentation explaining why the medication was held or if the physician was informed. Additionally, Resident R40, who has multiple diagnoses including Type 2 diabetes and schizoaffective disorder, was observed using a straw despite a physician order prohibiting straw use due to aspiration risk. The resident's care plan lacked documentation of a comprehensive plan addressing the swallowing difficulties. An observation confirmed the resident was using a straw, and the speech therapist verified that the resident should not have been using one. These deficiencies highlight the facility's failure to adhere to physician orders and document necessary actions, which are critical for managing the residents' health conditions effectively. The lack of proper documentation and communication with physicians regarding medication administration and adaptive equipment use contributed to these deficiencies.
Failure to Prevent Pressure Ulcers in Residents
Penalty
Summary
The facility failed to implement appropriate treatment and services to prevent pressure ulcers for two residents, R59 and R177. Resident R59, who had a cognitive communication deficit and severe protein-calorie malnutrition, was at risk for developing pressure ulcers. Despite physician orders to offload the left heel at all times, observations revealed that the resident's left heel was placed against the footboard of the bed without proper offloading measures. Interviews with staff confirmed that the resident's foot was not offloaded as ordered, and the resident reported pain in the left heel. Similarly, Resident R177, who also had a cognitive communication deficit, severe protein-calorie malnutrition, and a pressure ulcer on the left heel, was observed lying in bed without any offloading measures for the heels. The heel boots intended for offloading were found on the nightstand and outside the room on a linen cart, indicating a failure to follow physician orders to offload heels at all times. This observation was confirmed by a Licensed Practical Nurse, highlighting the facility's failure to adhere to its policy on pressure ulcer prevention.
Failure to Provide Proper Head/Neck Positioning for Resident with Limited ROM
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion, specifically in maintaining proper head and neck positioning. Observations on two separate occasions revealed that the resident was seated in a Geri-chair with their head tilted to the right side, unsupported, and without any positioning devices. This was noted during a feeding session by a nurse aide, where the resident's head remained unsupported, indicating a lack of intervention for head/neck positioning. The resident's care plan, dated several months prior, included a restorative nursing program aimed at preventing functional decline through daily activities. However, it lacked specific interventions or services for head/neck positioning. An interview with the Rehab director confirmed the presence of a neck contracture and acknowledged the absence of any interventions to address this issue or prevent further decline in the resident's functional range of motion.
Controlled Drug Discrepancy in Medication Room
Penalty
Summary
The facility failed to ensure accurate accounting of controlled drugs in the B unit medication room. During an observation, a Licensed Practical Nurse (LPN) identified a discrepancy in the amount of lorazepam liquid medication stored in the refrigerator. The bottle contained 14 ml of medication, whereas the narcotic count sheet indicated that only 4.5 ml should have been left. The LPN noted this discrepancy two days prior, observing that there was almost 10 ml more than accounted for. The Director of Nursing confirmed the discrepancy during an interview.
Failure to Monitor Antipsychotic Medication Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically concerning the use of antipsychotic medication. A review of the clinical records and interviews with staff revealed that the facility did not adequately monitor a resident who was prescribed Quetiapine Fumarate for schizophrenia. The pharmacy consultant had recommended monitoring for potential adverse effects such as ataxia, falls, extrapyramidal symptoms, tardive dyskinesia, akathisia, hypoglycemia, hyperprolactinemia, and hyperlipidemia. However, there was no evidence in the clinical records that the facility consistently monitored the resident for these adverse effects. The Assistant Director of Nursing confirmed that the resident was not monitored for the adverse effects of the antipsychotic medication as recommended. The resident's care plan included an intervention to monitor the effectiveness and tolerance of the medication, with instructions to report any abnormal findings to the RN and physician. Despite this, the necessary monitoring was not conducted, leading to a deficiency in the resident's care as per the regulations outlined in 28 Pa. Code 211.12(d)(1)(3)(5) regarding nursing services.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to provide accurate meal trays and accommodate food preferences for several residents, as observed and confirmed through staff interviews. One resident reported that their preference for double portions of protein was not honored, and this was confirmed when their lunch tray was missing the requested double meat sandwich. Additionally, during a Resident Council Meeting, multiple residents reported that their meal tickets often lacked items, and the facility frequently ran out of certain food items like French fries or potato tots. Observations also revealed that another resident's preference for canned fruit was not met, and a different resident did not receive the extra gravy they requested. These deficiencies were confirmed by staff members, indicating a failure to adhere to the facility's policy on accommodating residents' food preferences.
Failure to Maintain 1:1 Supervision for Residents with Suicidal Ideations
Penalty
Summary
The facility failed to maintain appropriate supervision for two residents, R1 and R6, who were both on 1:1 supervision due to suicidal ideations. Resident R1, with a moderate cognitive impairment and a diagnosis of depression, expressed suicidal thoughts during an assessment. Despite a physician's order for 1:1 supervision, Resident R1 was left unattended in a hospital triage area by the facility van driver, Employee E5, who was unaware of the supervision requirement. This lapse in supervision allowed Resident R1 to leave the hospital unsupervised. Similarly, Resident R6, who had moderate cognitive impairment and diagnoses of anxiety, schizophrenia, and depression, was also on 1:1 supervision for behaviors including suicidal ideations. However, observations revealed that Resident R6 was left alone in her room without the required supervision. This indicates a failure in adhering to the prescribed care plan and physician's orders for maintaining 1:1 supervision for residents with significant mental health needs.
Resident Abuse by Nursing Staff
Penalty
Summary
The facility failed to ensure that a resident was free from verbal, physical, and psychological abuse by a nursing staff member. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including General Anxiety Disorder, Vascular Dementia, and Major Depressive Disorder. The resident was roughly handled, yelled at with profane language, and struck in the chest by a nurse aide, resulting in injuries to the resident's fourth finger on the right hand and chest area. The resident also demonstrated signs of fear when approached by nursing staff following the incident. The abuse was witnessed by another nurse aide, who observed the perpetrator forcefully pushing the resident into a chair and punching him in the chest. The witness also reported that the resident flinched and covered his face when approached, indicating fear. The incident was reported to the Director of Nursing, and the resident was assessed for injuries, which included a scratch to the right pointer finger and redness on the chest. The police were notified, and the facility began an investigation. Video footage confirmed the rough handling and abuse by the nurse aide. The footage showed the nurse aide pushing the resident down the hallway and into a day room, where the abuse occurred. Statements from other staff members corroborated the events, with one staff member hearing the perpetrator threaten the resident with further harm. The facility's policies on abuse prevention and dementia care were reviewed, revealing that the staff failed to adhere to these policies, resulting in the abuse of the resident.
Failure to Protect Resident from Abuse
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility, resulting in an immediate jeopardy situation for a resident. The resident, who had severe cognitive impairment and multiple diagnoses including General Anxiety Disorder and Vascular Dementia, was subjected to physical and verbal abuse by a nurse aide. The incident occurred when the resident was being resistive with staff and was forcefully pushed into a chair and punched in the chest by the nurse aide. This resulted in redness to the chest area and a skin tear on the resident's finger, causing pain that required medical attention and pain management. Facility documentation and staff interviews confirmed the abuse. A written statement from another nurse aide detailed the abusive behavior, including the use of profanity and threats by the offending nurse aide. The incident was immediately reported to the DON, and emergency services were called. Multiple staff members witnessed the abusive behavior and provided statements that corroborated the events, describing the rough handling and physical assault on the resident. Interviews with the NHA and Assistant Director of Nursing confirmed the incident and the subsequent termination of the offending nurse aide. The failure of the NHA and DON to establish and maintain effective systems to protect residents from abuse was evident, as they did not ensure a safe environment for the resident. This deficiency highlights a significant lapse in the management and oversight responsibilities of the facility's leadership, contributing to the immediate jeopardy situation.
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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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