Rose Meadows Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 1717 Skyline Drive, Pittsburgh, Pennsylvania 15227
- CMS Provider Number
- 395745
- Inspections on file
- 51
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Rose Meadows Health & Rehab Center during CMS and state inspections, most recent first.
A resident with cellulitis, muscle weakness, and an MDS indicating a need for dependent, two-person assistance with transfers was injured during a wheelchair-to-bed transfer performed by a single CNA. During the transfer, the resident’s leg struck or was dragged along the bed frame, causing a significant laceration to the lower leg that required sutures. At the time of the incident, the resident’s care plan did not yet reflect the two-person transfer requirement, and facility leadership later acknowledged that adequate supervision to prevent the injury had not been provided.
Multiple live and dead cockroaches, as well as pest debris and waste, were observed in various areas of the main kitchen, including under equipment and behind counters. Staff confirmed ongoing pest control issues and acknowledged the facility's failure to maintain an effective pest control program.
A resident dependent on staff for transfers, with hemiplegia and a history of falls, was injured when a CNA attempted a transfer alone, contrary to the care plan requiring two staff and a mechanical lift. The resident slid from the bed and sustained a left humerus fracture, with documentation and staff interviews confirming the care plan was not followed.
A resident with hemiplegia and a history of falls, who required two-person assistance for transfers, was injured when a CNA attempted a transfer alone, resulting in a fall and a left humerus fracture. Despite staff training and clear care plan instructions, the required supervision was not provided, leading to actual harm.
The facility failed to protect two residents from abuse and neglect. One resident did not receive care during a shift, and another experienced discomfort from an LPN during medication administration. The facility's investigation was inconclusive, and there was a lack of documentation on staff re-education.
The facility failed to identify, investigate, and report potential abuse and neglect for four residents. Incidents included a resident being sent to an appointment improperly dressed, another not receiving care due to staff attending to other residents, a resident unable to get out of bed due to perceived lack of lift pads, and a resident not being assisted into bed as requested. The facility's policies on timely identification and reporting of such incidents were not followed.
The facility failed to notify physicians of abnormal blood glucose levels and did not assess residents for hyperglycemia and hypoglycemia, affecting multiple residents. Residents with diabetes were not monitored for treatment effectiveness, and abnormal results were not communicated to physicians. Facility policies on glucose monitoring and condition change notifications were not followed, leading to deficiencies in care and documentation.
The facility failed to administer medications as ordered, resulting in significant errors for residents with diabetes. Insulin was given contrary to physician orders, and insulin pens were not primed before administration. The DON confirmed these deficiencies.
An LPN failed to maintain infection control practices during a dressing change by not cleansing scissors between handling soiled and clean items, leading to potential cross-contamination. Despite following some aseptic practices, the oversight was confirmed by the LPN and the Director of Nursing, violating facility policies and Pennsylvania Code regulations.
Failure to Provide Required Two-Person Assistance During Transfer Resulting in Laceration
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance during a transfer, resulting in a laceration that required sutures for one resident. The resident had diagnoses including cellulitis and muscle weakness, and the MDS dated 1/11/26 documented that the resident required dependent assistance from two or more helpers for chair/bed-to-chair transfers. On 2/5/26, while being transferred from a wheelchair to bed, the resident’s left leg struck or was dragged along the edge of the bed, causing a laceration to the left lateral lower leg. An on-call physician note documented a 6 cm by 0.5 cm by 0.25 cm laceration with some earlier bleeding, and a nursing progress note later that day described a 6 cm by 0.5 cm by 0.0 cm laceration, with the resident stating that their leg was dragged on the side of the bed during the transfer. Staff documentation and interviews showed that the transfer was performed by a single CNA without another employee assisting, despite the resident’s documented need for two-person assistance for transfers. The CNA confirmed via phone statement that they transferred the resident from the wheelchair to the bed without another employee. At the time of the incident, the resident’s care plan did not yet include the requirement for two-person assistance with all transfers; this intervention was not initiated in the care plan until the day after the incident. During an interview, the Nursing Home Administrator and the DON confirmed that the facility failed to provide adequate supervision to prevent the injury that resulted in the laceration requiring sutures.
Failure to Maintain Effective Pest Control in Main Kitchen
Penalty
Summary
Surveyors observed multiple instances of cockroach activity and pest evidence in the Main Kitchen, including one live cockroach on the wall of the food service hallway, two dead cockroaches in the food service staff restroom, four live cockroaches under the range in the food service preparation area, and food waste debris and dead cockroaches behind food service counters. Additionally, cockroach waste was noted on the wall in the food cart storage area. During staff interviews, the Food Service Director confirmed an ongoing pest control issue in the main kitchen, and the DON acknowledged the facility's failure to maintain an effective pest control program in this area.
Failure to Follow Transfer Protocols Resulting in Resident Injury
Penalty
Summary
A resident with a history of hemiplegia, diabetes, and previous falls was admitted and readmitted to the facility, requiring total assistance from two staff members and a mechanical lift for transfers and for moving from lying to sitting. The resident's care plan and Kardex both specified the need for two or more helpers for all transfers. Despite these documented requirements, a CNA attempted to transfer the resident alone by sitting her at the edge of the bed while waiting for help. The force of this action caused the resident to slide forward, resulting in her falling to the floor and sustaining a left humerus fracture. The CNA involved had recently been hired and had completed competencies related to safe transfers and following care plans. However, the CNA did not adhere to the resident's care plan or the facility's documented transfer protocols, which directly led to the resident's fall and subsequent injury. The incident was documented in the facility's progress notes, incident report, and an x-ray confirmed the fracture. Interviews with staff and review of records confirmed that the resident's care plan and transfer requirements were clearly documented and accessible to staff through the Kardex. The failure to follow these established protocols resulted in actual harm to the resident, as evidenced by the fracture. The deficiency was identified as neglect, defined by the facility as the failure to provide necessary goods and services to avoid physical harm, pain, or emotional distress.
Failure to Provide Adequate Supervision During Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with hemiplegia, diabetes, and a history of falls, who was dependent on staff for bed-to-chair transfers and required the assistance of two staff members for transfers, was not provided adequate supervision during a transfer. The resident's care plan and facility policy specified that two staff members were required for all transfers and for moving the resident from lying to sitting on the side of the bed. Despite this, a CNA attempted to transfer the resident alone, resulting in the resident sliding out of bed and sustaining a left humerus fracture. The CNA involved had received training and demonstrated competencies in safe transfer methods and was aware of the resident's care requirements. The incident report and the CNA's written statement confirmed that the CNA sat the resident at the edge of the bed while waiting for help, but the resident slid forward and fell, injuring her shoulder. The facility's policies emphasized minimizing safety hazards and ensuring safe handling and transfers, but these were not followed in this instance. Interviews with multiple CNAs, LPNs, and RNs confirmed that staff were trained to use the Kardex and care plans to guide safe care and that education on safe transfers was provided. However, the failure to follow the resident's care plan and facility policy directly led to the resident's fall and injury. The deficiency was identified as past noncompliance, and facility leadership acknowledged the failure to provide adequate supervision to prevent the accident.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to ensure that residents were free from abuse, neglect, or misappropriation of property, as evidenced by incidents involving two residents. One resident, identified as R190, was reportedly not provided care by a nurse aide during a specific shift, as stated by the resident's roommate. The facility's documentation did not show any care provided to this resident until late in the evening, despite the resident being in isolation due to a positive COVID-19 diagnosis and having multiple medical conditions, including encephalopathy and dementia. The facility's investigation could not confirm whether neglect occurred, and there was a lack of documentation indicating that the involved staff member received re-education on abuse prevention. Another incident involved a resident, identified as R400, who reported discomfort caused by an LPN while administering medication. The resident stated that the LPN stretched her hand painfully while checking for a pill. The LPN's account differed, indicating that she found a pill in the resident's hand and placed it in the resident's mouth. The resident had a history of serious medical conditions, including diabetes and kidney failure, and was found unresponsive in her apartment prior to admission. The Director of Nursing confirmed the facility's failure to protect these residents from abuse and neglect.
Failure to Identify and Report Potential Abuse and Neglect
Penalty
Summary
The facility failed to identify, investigate, and report potential abuse and neglect for four residents. One resident was sent to an appointment not appropriately dressed, which was identified as a failure to freshen up the resident before leaving. Another resident's daughter reported that her parent was not provided care on a specific date, and it was found that the assigned nurse aide was attending to another resident, with care being provided by a different aide. A third resident reported that staff would not assist him out of bed due to a lack of lift pads, although the facility had sufficient supplies. This resident also reported poor customer service, but the facility did not specify the nature of the service issues. The fourth resident requested assistance to be put into bed, but the assigned nurse aide went on break, and another nurse eventually assisted the resident. This resident required a two-person transfer with a hoyer lift, as indicated in his care plan. The Director of Nursing confirmed the facility's failure to properly address these incidents, which were not adequately identified, investigated, or reported as potential abuse or neglect. The facility's policies on abuse, neglect, and misappropriation emphasize the importance of timely identification and reporting of incidents that could place residents at risk, which was not adhered to in these cases.
Failure to Monitor and Report Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to notify physicians of abnormal capillary blood glucose (CBG) levels and did not assess residents for hyperglycemia and hypoglycemia, affecting three of six residents reviewed. Specifically, residents with diabetes were not monitored for the effectiveness of their treatment, and abnormal CBG results were not communicated to their physicians. This lack of communication and assessment was evident in the cases of residents who had documented low blood glucose levels, yet no follow-up actions were taken as per the care plan or physician's orders. The facility's policies on blood glucose monitoring and notification of changes in condition were not adhered to, as evidenced by the failure to document and report significant changes in residents' conditions. For instance, residents with CBG levels below 70 mg/dL were not assessed for hypoglycemia, and their physicians were not notified of these critical results. Additionally, the facility did not document the interventions taken to address these abnormal findings, which is a requirement under their clinical documentation standards. Interviews with nursing staff revealed inconsistencies in the handling of abnormal blood glucose levels, with some staff indicating they would notify a physician for levels below 70 mg/dL, while others did not follow through with this protocol. The Director of Nursing confirmed these deficiencies, acknowledging the facility's failure to document hypo-/hyperglycemic episodes, follow physician orders, and notify medical providers of changes in residents' conditions. This lack of adherence to established protocols and documentation standards contributed to the deficiencies identified in the report.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for several residents, leading to significant medication errors. Resident R52, who has diabetes and chronic kidney disease, received insulin on multiple occasions despite physician orders to hold the medication if blood sugar levels were below 120. Similarly, Resident R69, diagnosed with diabetes and dementia, did not have a documented blood sugar result on a specific date, and insulin was not administered as ordered. The Director of Nursing confirmed these findings, indicating a failure in adhering to physician orders for these residents. Additionally, the facility did not ensure that insulin pens were primed before administration, as observed in the cases of Residents R301 and R24. Resident R301, with a history of diabetes and muscle weakness, received insulin without the pen being primed, as did Resident R24, who has diabetes and high blood pressure. Both LPNs involved in these incidents confirmed the failure to prime the insulin pens before administration. The Director of Nursing acknowledged that the facility did not administer the correct dose of insulin due to this oversight.
Infection Control Breach During Dressing Change
Penalty
Summary
The facility failed to maintain proper infection control practices during a dressing change, as observed during a survey. The Licensed Practical Nurse (LPN) involved did not cleanse the scissors used between handling soiled and clean items, which could lead to cross-contamination. The dressing change procedure involved multiple steps where the same uncleaned scissors were used to cut tape, dressings, and gauze for wounds on both legs and the sacral area of a resident. Despite using alcohol-based hand sanitizer and changing gloves between tasks, the failure to clean the scissors was a significant oversight. The facility's policies on skin care, wound management, and infection control were reviewed, indicating that residents should reside in a safe environment with reduced infection risks. However, during the dressing change, the LPN did not adhere to these policies, as confirmed in interviews with the LPN and the Director of Nursing. The Director of Nursing acknowledged the failure to prevent cross-contamination, which is a violation of several Pennsylvania Code regulations related to staff development, licensee responsibility, management, and resident care policies.
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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