Orwigsburg Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Orwigsburg, Pennsylvania.
- Location
- 1000 Orwigsburg Manor Dr, Orwigsburg, Pennsylvania 17961
- CMS Provider Number
- 395878
- Inspections on file
- 21
- Latest survey
- November 12, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Orwigsburg Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple sclerosis, who had declined consent for photography, had personal care items photographed by a nurse aide. The photograph was then shown to another aide, despite facility policy prohibiting such actions and the resident's explicit refusal of consent.
Staff did not consistently follow physician orders for medication administration and oxygen therapy for four residents. This included administering blood pressure medications outside of ordered parameters and failing to provide ordered oxygen therapy to a resident with chronic respiratory failure.
A resident with diagnoses of anxiety, depression, and atrial fibrillation was inaccurately documented as having a tracheostomy on the MDS assessment, despite no supporting clinical record or care plan. The Administrator confirmed the inaccuracy during staff interview.
Two residents with histories of substance abuse and other medical conditions were able to obtain and use methamphetamine within the facility, with one resident selling the substance to another. Staff failed to ensure all areas were searched for additional hazards, resulting in an Immediate Jeopardy situation.
The facility failed to provide adequate grooming and personal hygiene for several residents, who were observed with long, jagged fingernails despite needing assistance with ADLs. Residents expressed dissatisfaction with the lack of nail care, and a group interview confirmed that routine nail care was not consistently provided. The DON stated that nail care should occur during showers, but this was not being followed.
The facility failed to assess and implement scheduled toileting programs for two residents, despite indications from Bowel and Bladder Program Screeners that they were candidates for such programs. Both residents required assistance for toileting and were frequently incontinent, yet there was no documented evidence of a toileting program being implemented, as confirmed by the DON.
A facility failed to offer non-pharmacological interventions before administering PRN anti-anxiety medication to a resident with schizophrenia and anxiety. The resident received alprazolam 30 times over two months without documented attempts of alternative interventions. The DON confirmed the lack of documentation.
A resident with diabetes and congestive heart failure, who was alert and able to communicate, had a care plan to honor his food preferences due to nutritional risk. However, he frequently received disliked items on his meal trays. During an observation, rice was served despite being listed as a disliked food, and the resident confirmed he would not eat it.
A resident with dysphagia and aphasia was not provided with the prescribed adaptive equipment, such as a two-handled cup, during meals. Despite a physician's order and occupational therapy recommendations, the resident was observed without the necessary equipment on multiple occasions. A nurse confirmed the oversight, highlighting a failure to comply with care directives.
A facility failed to follow its transmission-based precautions policy for a resident with MRSA. Despite a posted sign requiring gowns and gloves, a nurse aide and a visitor were observed in the resident's room without gowns. The Infection Preventionist confirmed the policy breach.
Unauthorized Photography Violates Resident Privacy
Penalty
Summary
The facility failed to protect a resident's right to privacy and confidentiality by allowing unauthorized photography of personal care items. According to facility policy, resident privacy and security must be maintained, and clinical records showed that the resident, who had multiple sclerosis and no cognitive impairment, had explicitly declined authorization for any images to be taken or used. Despite this, documentation revealed that a nurse aide took a photograph of the resident's waste products and showed it to another nurse aide, who confirmed that similar photographs had been shown in the past. The Nursing Home Administrator acknowledged that this action was against facility policy.
Failure to Follow Physician Orders for Medications and Oxygen Therapy
Penalty
Summary
The facility failed to follow physician orders for four residents with significant medical conditions. For one resident with chronic kidney failure, congestive heart failure, and diabetes, staff administered isosorbide mononitrate on multiple occasions when the resident's systolic blood pressure (SBP) was below the physician-ordered threshold of 115 mmHg. Similarly, another resident with hypertension received losartan potassium three times when their SBP was below the ordered hold parameter of 110 mmHg, and a third resident with hypertension was given metoprolol tartrate six times when their SBP was also below 110 mmHg, contrary to physician instructions. These actions were confirmed through medication administration record reviews and staff interviews. Additionally, a resident with partial paralysis following a stroke and chronic respiratory failure with hypoxia was observed without the ordered oxygen therapy. The resident was found in a hallway with an empty oxygen tank and no nasal cannula, despite a physician's order for continuous oxygen administration at two liters per minute. Staff confirmed that the oxygen was not administered as ordered. These findings demonstrate that the facility did not consistently implement physician orders for medication and oxygen therapy for multiple residents.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for one of 25 sampled residents. Clinical record review showed that the resident had diagnoses of anxiety, depression, and atrial fibrillation. However, the MDS assessment incorrectly indicated that the resident had a tracheostomy, despite no supporting physician's orders or care plan documentation in the clinical record. During an interview, the Administrator confirmed that the MDS was inaccurate and that the resident did not have a tracheostomy. This deficiency was identified through clinical record review and staff interview, which revealed a discrepancy between the resident's documented medical conditions and the information recorded on the MDS assessment.
Failure to Prevent Resident Access to Illegal Substances Creates Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards by not preventing access to illegal substances for two residents. One resident, with a history of alcoholic cirrhosis, major depressive disorder, and diabetes, and another resident, with chronic pain, alcohol abuse, and psychoactive substance abuse, were both able to obtain and use methamphetamine within the facility. The first resident was identified as the source of the substance, selling it to the second resident, who then kept it in his room. Both residents were independently ambulatory, and one had mild cognitive impairment while the other had no cognitive impairment. The presence and use of methamphetamine were confirmed through interviews, clinical record review, and drug testing. The facility's failure extended beyond these two residents, as staff only searched the unit and common areas where the incident was discovered, neglecting to search other resident areas and common spaces on another nursing unit and the first floor. This incomplete response left other areas potentially unsafe and did not ensure that all residents were protected from similar hazards. The deficiency was identified through clinical record review, facility documentation, and interviews with residents and staff, resulting in an Immediate Jeopardy situation.
Failure to Provide Adequate Grooming and Personal Hygiene
Penalty
Summary
The facility failed to provide adequate grooming and personal hygiene services for four residents, as observed and documented by surveyors. Resident 17, who had diabetes and a history of respiratory disease, became more dependent on staff for activities of daily living (ADLs) after a hospital stay. Despite this increased need, she was observed with long and jagged nails on multiple occasions, and she reported that staff had not assisted her with nail care. Similarly, Resident 31, who required substantial assistance for ADLs due to diabetes and hypertension, was observed with long, yellow, and jagged fingernails over several days, expressing a preference for short nails and a need for assistance. Resident 68, diagnosed with macular degeneration and anxiety, also required substantial assistance for ADLs and was observed with long, yellow, jagged fingernails with debris underneath. He expressed frustration over the lack of assistance with nail care. Resident 87, who had a history of stroke and osteoarthritis, was dependent on staff for personal hygiene and was observed with long, jagged fingernails, stating he could not cut them himself. A group interview with other residents revealed that routine nail care was not consistently provided as part of ADL assistance. The Director of Nursing indicated that nail care should be performed during residents' showers, but this was not being adequately implemented.
Failure to Implement Scheduled Toileting Programs
Penalty
Summary
The facility failed to assess bladder incontinence and provide services to restore bladder function for two residents. According to the facility's policy on urinary continence and incontinence, staff were required to complete a urinary incontinence assessment periodically and when there was a change in voiding. However, for one resident with diagnoses including anxiety and hemiplegia, the clinical record review showed that although a Bowel and Bladder Program Screener indicated the resident was a candidate for a scheduled toileting program, there was no documented evidence that such a program was implemented. The resident's type of urinary incontinence was not identified, and the Minimum Data Set (MDS) assessment indicated the resident was incontinent of urine and required staff assistance for toileting. Similarly, another resident with diabetes mellitus was identified as a candidate for a scheduled toileting program through multiple Bowel and Bladder Program Screeners. Despite this, the resident was frequently incontinent of urine and not on a toileting program, as confirmed by the MDS assessment. The type of urinary incontinence was not identified, and there was no documentation of a scheduled toileting program being implemented. The Director of Nursing confirmed the lack of documented evidence for the assessment and implementation of toileting programs for these residents.
Failure to Implement Non-Pharmacological Interventions Before PRN Medication
Penalty
Summary
The facility failed to offer non-pharmacological interventions before administering as-needed anti-anxiety medication to one resident. The clinical record review showed that the resident, who had diagnoses of schizophrenia and anxiety, was prescribed alprazolam to be given every eight hours as needed over a period of 14 days. During June and July 2024, the medication was administered 30 times without documented evidence of attempts to use non-pharmacological interventions first. In an interview, the Director of Nursing confirmed the absence of documentation regarding non-pharmacological interventions prior to the administration of the anti-anxiety medication. This deficiency was identified during a survey, as per the requirements of 28 Pa. code 211.12(d)(1)(5) Nursing services.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate a resident's food preferences, as evidenced by the case of a resident with diabetes mellitus and congestive heart failure. The resident was alert and able to communicate his needs, as indicated in a Minimum Data Set assessment. His care plan included an intervention to honor his food preferences due to his potential nutritional risk. However, on July 23, 2024, the resident reported frequently receiving disliked items on his meal trays. During an observation of his lunch tray, rice was served as a side dish, despite being listed as a disliked food on his meal ticket. The resident confirmed he did not want the rice and would not eat it.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive equipment to assist with eating meals for one of the residents. Resident 1, who had diagnoses of dysphagia and aphasia, was ordered by a physician on March 19, 2024, to be provided with a two-handled cup at all meals. An occupational therapy note dated July 17, 2024, recommended the continued use of a two-handled mug or a regular mug/cup with a lid and straw to aid the resident's independence. However, observations on July 23 and July 25, 2024, revealed that the resident was in the dining room without the prescribed adaptive equipment for her beverages. In an interview on July 26, 2024, a registered nurse confirmed that the resident should have received her drink in a two-handled cup at all meals, indicating a failure to comply with the physician's order and occupational therapy recommendations.
Failure to Follow Transmission-Based Precautions
Penalty
Summary
The facility failed to adhere to its policy on transmission-based precautions (TBP) and the use of personal protective equipment (PPE) for one resident. The policy, last reviewed on January 16, 2024, required additional measures to protect staff, visitors, and other residents from infections when a resident was diagnosed with specific pathogens. Resident 47, who was admitted with diagnoses including dementia, pneumonia, and methicillin-resistant Staphylococcus aureus (MRSA) in the sputum, was ordered by a physician on May 13, 2024, to be on TBP. On July 24, 2024, a sign was posted outside the resident's room indicating the need for TBP, including the use of gowns and gloves. However, observations revealed that a nurse aide provided care without wearing a gown, and a visitor was also seen in the room without a gown. The Infection Preventionist confirmed that the policy was not followed, as all staff and visitors should have worn appropriate protective equipment.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
