Menno Haven Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chambersburg, Pennsylvania.
- Location
- 2055 Scotland Avenue, Chambersburg, Pennsylvania 17201
- CMS Provider Number
- 396145
- Inspections on file
- 19
- Latest survey
- August 26, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Menno Haven Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not maintain hot food at required temperatures during meal service, resulting in several residents receiving lukewarm and unappetizing meals. Food items that were initially at safe temperatures in the kitchen were observed to be below the facility's standard by the time they reached residents, and multiple residents reported dissatisfaction with the temperature of their meals.
A resident who required non-invasive ventilation for sleep apnea was using a CPAP device at bedtime without a documented physician's order, despite facility policy requiring such an order. This was confirmed through record review and staff interview.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified during the survey.
The facility failed to create comprehensive care plans for two residents, one requiring a CPAP machine for sleep apnea and another self-administering cough drops. The care plans were not updated to reflect changes in their care needs, as confirmed by the Nursing Home Administrator.
The facility was found to be in violation of its food handling policies, with hot dogs thawing at room temperature and several food items in the kitchen not being labeled, dated, or secured. The Director of Dietary and the Executive Director of Culinary confirmed these practices were against policy.
The facility failed to maintain complete and accurate clinical records for three residents, as staff marked required exercises as Not Applicable or left documentation blank, contrary to care plans. This issue was confirmed by the Nursing Home Administrator.
A facility failed to notify a physician about a significant weight gain in a resident with end-stage kidney disease and on diuretics. The resident's weight increased by 12.8 pounds in one day, but there was no documented evidence of physician notification, as confirmed by an RN Clinical Manager.
A facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by policy. The resident, who had an indwelling urinary catheter and was on Enhanced Barrier Precautions, did not have these needs documented in their care plan. Observations confirmed the presence of the catheter and precautions, but the necessary documentation was missing, as confirmed by the Nursing Home Administrator.
A facility failed to administer a diuretic to a resident as prescribed, despite significant weight gain indicating the need for the medication. The resident, who was cognitively intact and dependent on staff, had a care plan requiring Bumex for edema if there was a 2-pound weight increase. The resident's weight increased significantly over two days, but the medication was not given, as confirmed by the RN Clinical Manager.
The facility's QAPI committee failed to address recurring deficiencies in quality of care and sanitary food preparation and storage. Despite having plans of correction, the facility was cited again for these issues, indicating ineffective implementation of corrective measures.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve food items at appetizing and safe temperatures, as required by its own dietary policy. The policy specified that hot foods should be held at 155-170 degrees Fahrenheit at the tray line and served at 135-155 degrees Fahrenheit, while cold foods should be held at 31-41 degrees Fahrenheit and served at 33-50 degrees Fahrenheit. However, observations and temperature logs revealed that while the macaroni and cheese and stewed tomatoes were at appropriate temperatures in the kitchen (184°F and 168°F, respectively), by the time they were served to residents, their temperatures had dropped to 126.3°F and 130.8°F, which is below the facility's standard for hot food service. Multiple residents reported that their food was consistently cold and unappetizing, with one stating that the food would taste better if it was not always cold. Staff interviews confirmed that the food should have been hotter at the time of service. The deficiency was identified through review of facility policies, food production logs, direct observation of food service, and interviews with residents and staff.
Failure to Obtain Physician Order for CPAP Use
Penalty
Summary
The facility failed to obtain a physician's order for the use of a CPAP device for one resident who required non-invasive ventilation for sleep apnea. According to facility policy, an order specifying the use and settings of the CPAP device must be obtained from a practitioner. Documentation reviewed included an admission MDS assessment indicating the resident was cognitively intact and used non-invasive ventilation, a care plan referencing CPAP use per physician's order, and a nursing note confirming CPAP use at bedtime. However, there was no documented evidence of a physician's order for the CPAP, a fact confirmed by the Director of Nursing during an interview.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive program but does not provide specific details about individual residents, staff actions, or particular infection control lapses observed during the survey.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, which led to deficiencies in addressing their specific care needs. For one resident, who had a diagnosis of dementia and required the use of a CPAP machine for obstructive sleep apnea, the care plan was initially resolved because the resident was not using the CPAP. However, after the resident's wife convinced him to use the CPAP again, the facility did not develop a new individualized care plan to address this change in the resident's care needs. This oversight was confirmed during an interview with the Nursing Home Administrator. Another resident, who was capable of understanding and self-administering medication, was found with cough drops in his room. Although a new physician's order was obtained to allow the resident to have cough drops at his bedside and self-administer them as needed, the facility did not develop an individualized care plan to document and support this ability. This lack of documentation was also confirmed by the Nursing Home Administrator during an interview. These deficiencies indicate a failure to adhere to the facility's policy on comprehensive care plans, which requires the development of person-centered plans with measurable objectives and timeframes.
Improper Food Thawing and Storage Practices
Penalty
Summary
The facility failed to adhere to its policies regarding the proper thawing and storage of food, as observed during a survey. Specifically, 38 hot dogs were found thawing at room temperature on a counter, contrary to the policy that prohibits thawing food at room temperature. Additionally, several food items in the kitchen were not labeled, dated, or secured as required. These included a cup of sage in a plastic bag, a piping bag full of whipped cream, and three pounds of dry spaghetti, all of which were undated and, in some cases, unsecured. The Director of Dietary and the Executive Director of Culinary confirmed these practices were against the facility's policies.
Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented clinical records for three residents. For Resident 11, the admission Minimum Data Set (MDS) assessment indicated the resident was understood, could understand others, and had a hip fracture diagnosis. The care plan required the resident to perform specific exercises twice daily. However, nurse aide documentation for July and August 2024 showed these exercises were marked as Not Applicable (NA) on several occasions. Similarly, Resident 26, who had a cerebral vascular accident diagnosis, was also on a Restorative Nurse Program for active range of motion. The documentation for June, July, and August 2024 showed numerous instances where the exercises were marked as NA or left blank. Resident 29, with a hip fracture diagnosis, had similar documentation issues in July and August 2024. An interview with the Nursing Home Administrator confirmed that staff should document whether the resident received, did not receive, or refused the exercises, rather than marking them as NA or leaving blanks.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to ensure timely notification of a physician regarding a significant change in a resident's condition. The facility's policy, dated June 12, 2024, required that any changes in a resident's condition be communicated to the physician. Resident 11, who was cognitively intact and required substantial assistance for care, was on a diuretic medication for high blood pressure and had end-stage kidney disease. The resident's care plan required daily monitoring for the effectiveness of the diuretic, including daily weight checks. On July 31, 2024, the resident's weight was recorded at 204 pounds, and on August 1, 2024, the weight increased to 216.8 pounds, a gain of 12.8 pounds in one day. There was no documented evidence that the physician was notified of this significant weight gain. An interview with RN Clinical Manager 1 confirmed the lack of notification and acknowledged that it should have been addressed.
Failure to Implement Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by their policy. The policy, dated June 12, 2024, mandates that a baseline care plan should include essential healthcare information such as initial goals based on admission orders, physician's orders, dietary orders, therapy orders, and social services. This plan should be developed by the admitting or supervising nurse using information from the admission physical assessment, hospital transfer information, physician's orders, and discussions with the resident and their representative. However, for one resident, admitted on August 2, 2024, there was no documented evidence of a baseline care plan addressing the resident's needs related to an indwelling urinary catheter and Enhanced Barrier Precautions. The resident had specific physician's orders for the management of an indwelling urinary catheter, including daily care, periodic changes, and irrigation as needed for blockage. Additionally, the resident was placed on Enhanced Barrier Precautions to prevent the transmission of resistant organisms. Observations on August 5 and August 6, 2024, confirmed the presence of the catheter and the precautionary measures, but the baseline care plan did not reflect these critical care needs. The Nursing Home Administrator confirmed the absence of the necessary documentation for the baseline care plan, indicating a lapse in meeting the facility's policy requirements.
Failure to Administer Diuretic as Prescribed
Penalty
Summary
The facility failed to follow physician orders for a resident who was cognitively intact and dependent on staff for daily care needs. The resident was prescribed a diuretic, Bumex, to be administered as needed for edema if there was a 2-pound weight increase in one day. Despite a documented weight increase from 202 pounds to 204 pounds on one day, and a further increase to 216.8 pounds the following day, the resident did not receive the prescribed medication on either occasion. This oversight was confirmed by the RN Clinical Manager during an interview, indicating a failure to adhere to the physician's orders as documented in the resident's care plan and medication records.
Repeated Deficiencies in Quality of Care and Food Safety
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies in quality of care and sanitary food preparation and storage. During a survey ending in September 2023, the facility was cited for deficiencies in these areas and developed plans of correction that included conducting audits and reporting the results to the QAPI committee. However, the subsequent survey ending in August 2024 revealed that these deficiencies persisted, indicating that the QAPI committee did not effectively implement or maintain compliance with the corrective measures. Specifically, the facility was cited under F684 for failing to maintain compliance with quality of care regulations and under F812 for failing to ensure proper food preparation and storage. Despite having plans of correction in place, the facility's QAPI committee did not successfully address these issues, leading to repeated citations. The report highlights the facility's inability to correct these deficiencies, as evidenced by the repeated findings in the current survey.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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