Phoebe Allentown Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Allentown, Pennsylvania.
- Location
- 1925 Turner Street, Allentown, Pennsylvania 18104
- CMS Provider Number
- 395080
- Inspections on file
- 26
- Latest survey
- August 19, 2025
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Phoebe Allentown Health Care Center during CMS and state inspections, most recent first.
A resident with dementia and feeding difficulties, who required assistance with eating and was on a pureed diet, was served a meal in bed without utensils. The resident was observed attempting to eat the pureed food with his fingers, experiencing difficulty and unable to complete the meal in a dignified manner.
Two residents with hemiplegia and contractures did not have their prescribed hand or forearm splints applied as ordered by physicians and recommended by therapy, despite care plans indicating the need for these interventions. Observations showed the splints were not in use during multiple checks, and the DON confirmed they should have been applied.
A resident with dementia, anxiety, and a history of falls, who was identified as cognitively impaired and at risk for falls, experienced six falls over five months due to inadequate supervision. The resident's impulsive behaviors and repeated incidents, including falls from bed and chairs resulting in injury and hospital evaluation, indicate that staff did not provide sufficient oversight to prevent accidents.
A resident with muscle weakness and a history of stroke, who was incontinent and required two staff for transfers, waited approximately 27 minutes for staff to respond to her call bell after requesting assistance to be changed. The facility's expected response time for call bells was ten minutes or less, but the call bell remained unanswered for nearly half an hour, as confirmed by device records and staff interviews.
Two residents did not receive physician-ordered medications and wound care treatments as prescribed, with no documentation of administration or refusal. The DON confirmed that staff failed to document whether the medications and treatments were offered or provided on the specified dates.
The facility failed to properly store and label food items, leading to unsanitary conditions in the dietary department and unit pantries. Surveyors found expired and unlabeled food in the main kitchen and unit pantries, contrary to facility policy. The Culinary Services Manager acknowledged the oversight.
A resident with a history of stroke and muscle weakness, who was alert and oriented but dependent on staff for transfers, had a care plan indicating a preference to be out of bed by 9:00 a.m. Observations showed the resident remained in bed past this time on multiple occasions. The resident expressed a preference to be out of bed by 10:00 a.m. at the latest, which was not being met. The DON confirmed the resident's preference, highlighting the facility's failure to honor it.
The facility failed to develop comprehensive care plans for two residents. One resident with diabetes and chronic kidney disease lacked interventions for urinary incontinence in her care plan, despite being incontinent and on diuretics. Another resident with anxiety and depression had no documented interventions for psychotropic drug use, despite receiving antipsychotic and antidepressant medications. These deficiencies were confirmed by facility staff.
The facility failed to provide scheduled morning activities for several residents, leading to expressions of boredom and restlessness. Residents with various diagnoses, including dementia and Parkinson's disease, were observed without activities on the [NAME] Way nursing unit. Their care plans highlighted the importance of engaging in activities, yet the absence of scheduled activities on a specific day resulted in unmet needs.
A facility failed to follow a physician's order for a resident with congestive heart failure and hypertension, which required daily weight monitoring and provider notification for significant weight gain. There was no evidence of weight being obtained or refusal documented on several dates, as confirmed by the DON.
A facility failed to implement interventions to prevent further decline in a resident's range of motion. The resident, with a history of stroke and muscle weakness, was dependent on staff for care and had a physician's order for a right elbow splint. Observations showed the splint was not applied, and the resident reported difficulty in receiving assistance from staff, with only one nurse trained to apply the splint. The DON confirmed the staff's responsibility to apply the splint as ordered.
Failure to Provide Utensils Compromises Resident Dignity During Meal
Penalty
Summary
Staff failed to provide care and services in a manner that maintained a resident's dignity. Clinical record review showed that the resident had dementia with mood disturbance, feeding difficulties, was cognitively impaired, and required assistance with self-care, including eating. The care plan indicated the resident was at nutritional risk, required a mechanically altered diet, and was to receive pureed food with double portions. During observation, staff delivered the resident's lunch meal to his room while he was in bed, but did not provide any utensils on the tray. The resident attempted to eat his pureed meal, including mashed potatoes, with his fingers from the time the meal was served until the observation ended. The resident was observed having difficulty eating with his fingers and was unable to complete his meal in a dignified manner.
Failure to Apply Prescribed Splints for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to provide services and treatment to prevent further limitations in range of motion (ROM) for two residents with existing ROM limitations. Both residents had a history of stroke with hemiplegia affecting the non-dominant left side and were assessed as having limitations in ROM on one side of both upper and lower extremities. Care plans indicated the need for assistance with activities of daily living (ADLs), and occupational therapy discharge summaries recommended the use of hand or forearm splints. Physician orders specified that splints were to be applied continuously or daily, with regular checks for skin integrity. Despite these orders and care plan interventions, multiple observations revealed that both residents were not wearing their prescribed splints during various times of the day, both while in bed and seated in their wheelchairs. In one case, the splint was observed on the nightstand rather than on the resident. The Director of Nursing confirmed that the splints were to be applied as ordered for both residents, indicating that the facility did not follow physician orders and therapy recommendations to maintain or improve ROM.
Failure to Provide Adequate Supervision for Fall Prevention
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for a resident with dementia, mood disorder, anxiety, and a history of falling. Clinical records indicated that the resident was cognitively impaired, had impulsive behaviors, and was identified as being at risk for falls in both the care plan and fall risk assessments. Despite these documented risks, the resident experienced six falls over a five-month period, including multiple incidents of falling out of bed and out of chairs in various areas of the facility. Some of these falls resulted in injuries, such as a lump on the forehead, and one incident required hospital evaluation. The repeated falls demonstrate that staff did not provide sufficient supervision or interventions to prevent accidents for this high-risk resident.
Delayed Call Bell Response for Dependent Resident
Penalty
Summary
A resident with a history of muscle weakness and stroke, who was incontinent and required assistance from two staff members for transfers, experienced a significant delay in response to her call bell. On the observed date, the resident activated her call bell at 10:51 a.m. and it remained unanswered until 11:21 a.m., as confirmed by the Device Activity Report. During this period, the resident reported waiting approximately 20 minutes for assistance to be changed, and stated that extended wait times for call bell responses were a frequent occurrence. Staff did not enter the room to provide the requested assistance until 27 minutes after the call bell was activated. The DON confirmed that the facility's expected response time for call bells was ten minutes or less.
Failure to Administer and Document Physician-Ordered Medications and Treatments
Penalty
Summary
Staff failed to implement physician's orders for two residents. For one resident with dementia and anxiety, clinical records showed that morphine sulfate and haloperidol were not administered as ordered on multiple occasions, with no documentation of administration or resident refusal. Specifically, morphine was not given at 9:00 a.m. or 1:00 p.m. on one date, and haloperidol was not given at 9:00 a.m. on the same date and at 6:00 a.m. on another date. There was no evidence in the clinical record that the resident had refused these medications. For another resident with peripheral vascular disease, chronic kidney disease, and congestive heart failure, staff did not document the application of a prescribed wound care treatment on two separate dates. The physician's order required daily cleansing and dressing of a right wrist wound, but there was no evidence in the clinical record that the treatment was provided or refused by the resident. The DON confirmed that staff should have documented administration or refusal of medications and treatments, and that there was no such documentation for the identified dates.
Improper Food Storage and Labeling in Dietary Department
Penalty
Summary
The facility failed to adhere to its policies regarding the proper storage and labeling of food items, leading to unsanitary conditions in the dietary department and unit pantries. During a tour of the main kitchen, surveyors observed several violations, including an opened container of icing with an expired use-by date, improperly labeled raw pork loins, and an open container of coleslaw with an expired use-by date. Additionally, there was an opened bag of croissants without a date, and ice build-up was found on several opened boxes of food items in the walk-in freezer. In the unit kitchens, opened packages of whipped topping and a plated Danish were found without proper labeling. Further observations in the unit pantries revealed that food items were not labeled with residents' names or dates, contrary to facility policy. In the 2 East unit pantry, several opened food items, including a package of dates, a bottle of coffee creamer, shredded cheese, and a jar labeled as sour cherry and honey preserves, were found without proper labeling. Similarly, in the 3 East unit pantry, four sandwiches were found without any resident identification or date. The Culinary Services Manager acknowledged that these items should have been dated and legible, indicating a lapse in following established procedures.
Failure to Honor Resident's Preference for Out-of-Bed Time
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not adhering to the resident's preference to be out of bed by 9:00 a.m. The clinical record review indicated that the resident, who had a history of a stroke with residual right-sided weakness and muscle weakness, was alert and oriented but dependent on staff for transfers. The care plan specified that the resident preferred to be out of bed by 9:00 a.m. daily. However, observations on two consecutive days showed that the resident remained in bed past the preferred time. During an interview, the resident expressed a preference to be out of bed by 10:00 a.m. at the latest, but noted that this was not being met. The Director of Nursing confirmed the resident's preference to be out of bed by 9:00 a.m., acknowledging the failure to meet this preference.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, as identified during a clinical record review and staff interviews. Resident 33, who was admitted with diagnoses including diabetes and chronic kidney disease, was noted in the Minimum Data Set (MDS) Care Area Assessment (CAA) summary to have urinary incontinence that needed to be addressed in her care plan. Despite being always incontinent of urine and continuing the use of prescribed diuretics, there was no documented evidence of interventions for her incontinence in the current care plan. This was confirmed by the Director of Nursing during an interview. Similarly, Resident 231, admitted with anxiety and depression, was identified in the MDS CAA summary as requiring interventions for psychotropic drug use in the care plan. The medication administration record showed that the resident was receiving both an antipsychotic and an antidepressant, yet there was no documented evidence of interventions for managing the psychotropic drug use in the care plan. This deficiency was confirmed by the Administrator during an interview.
Failure to Provide Scheduled Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing activity program to meet the needs of five residents, as observed during a survey. The activities calendar for the week of August 5 through August 11, 2024, showed a lack of scheduled morning activities on the [NAME] Way nursing unit, particularly on August 7, 2024. Residents 20, 21, 107, 144, and 193 were observed in the lounge area during the morning hours without any scheduled activities, leading to expressions of boredom and restlessness. These residents had various diagnoses, including dementia, anxiety, depression, chronic kidney disease, congestive heart failure, and Parkinson's disease, and their care plans indicated the importance of engaging in activities. Resident 20, who had dementia, anxiety, and depression, expressed a need for cueing and setup to engage in activities, while Resident 21, with chronic kidney disease and depression, required assistance with activities and social interaction. Resident 107, with anxiety and Parkinson's disease, was independent in choosing leisure pursuits but was aware of the lack of morning activities. Resident 144, with dementia and Parkinson's disease, expressed that activities were repetitious, and Resident 193, with Alzheimer's dementia, was restless and repeatedly checked for activities. The absence of scheduled activities on August 7, 2024, led to these residents experiencing boredom and a lack of engagement, as confirmed by the administrator's acknowledgment of no scheduled morning activity on that day.
Failure to Implement Physician's Orders for Daily Weight Monitoring
Penalty
Summary
The facility failed to implement a physician's order for a resident diagnosed with congestive heart failure and hypertension. The order, dated April 19, 2024, required staff to obtain the resident's daily weight and notify the provider if there was a weight gain of three or more pounds in one day. However, there was no evidence that the resident's weight was obtained, nor was there documentation of the resident refusing to be weighed on multiple dates in June, July, and August 2024. This deficiency was confirmed during an interview with the Director of Nursing on August 8, 2024.
Failure to Implement ROM Interventions for Resident
Penalty
Summary
The facility failed to implement interventions to prevent further decline and/or improve range of motion for a resident with limited range of motion. Resident 40, who had a history of a stroke with residual right-sided weakness and muscle weakness, was dependent on staff for all upper and lower body care. A physician's order required the application of a splint to the resident's right elbow daily. However, observations on multiple occasions revealed that the splint was not in place, and the resident expressed that she wanted to wear the splint but had to wait for staff assistance. She reported asking for help multiple times without receiving it, and only one nurse was trained to apply the splint. The Director of Nursing confirmed that staff was supposed to apply the splint as ordered.
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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