Sena Kean Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Smethport, Pennsylvania.
- Location
- 17083 Route 6, Smethport, Pennsylvania 16749
- CMS Provider Number
- 395775
- Inspections on file
- 29
- Latest survey
- October 23, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Sena Kean Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents experienced actual harm when staff failed to follow care plans requiring two-person assistance for transfers and bed mobility. One resident suffered a femur fracture during a transfer performed by a single CNA, while another sustained a laceration above the right eyebrow after being rolled out of bed by one CNA instead of two, as required by their care plans and physician orders.
A resident with a history of left femur fracture and mobility issues was transferred by a CNA without the required two-person assist, contrary to physician orders and facility policy. During the transfer from a shower chair to a wheelchair, towels were placed under the resident's feet, leading to a slip and fall that resulted in a left hip/femur fracture. Staff interviews and documentation confirmed the transfer was not performed according to the care plan, resulting in actual harm.
A facility failed to follow a physician's order for a resident with a suprapubic catheter. Despite an order not to change the catheter, a nurse attempted to do so, removing the existing catheter and failing to insert a new one. This was confirmed by the Nursing Home Administrator and DON.
A facility failed to follow Enhanced Barrier Precautions during the care of a resident with a gastric tube. An LPN did not wear a gown, as required, and there was no signage or PPE available outside the resident's room. The deficiency was confirmed by the LPN and the Infection Preventionist, highlighting a lapse in infection control practices.
The facility failed to provide baseline care plan summaries to three residents or their representatives within 48 hours of admission, as required by policy. Despite having conditions such as COPD, hypertension, heart failure, hypothyroidism, hyperlipidemia, dementia, and dysphagia, the residents did not receive the necessary documentation outlining goals, medications, dietary instructions, and treatments. This deficiency was confirmed by a review of clinical records and an interview with the Regional Nurse Consultant.
A facility failed to ensure proper medication administration for a resident with chronic conditions, leaving medications unattended at the bedside. The resident reported that staff do not wait for them to take their pills, and a medication was found on the floor. An LPN was assisting other residents, and a nurse confirmed the breach of policy.
The facility failed to discard an outdated vial of Novolog Insulin on the West A Hall medication cart. The facility's policy requires checking expiration dates before administering medications and recording the opening date on multi-dose containers. A vial of Novolog Insulin, opened on 4/10/24, was found during an observation, exceeding the 28-day expiration period. An LPN confirmed the vial should have been discarded, violating facility policy and state regulations.
Failure to Follow Care Plans Results in Resident Harm
Penalty
Summary
The facility failed to protect two residents from neglect during care, resulting in actual harm. In the first incident, a resident with orders requiring transfer assistance from two staff members and a wheeled walker, and who was assessed as fully dependent for mobility, was transferred by a single CNA. During the transfer from a shower chair to a wheelchair, towels were placed under the resident's feet to keep them dry, but the resident stepped off the towels and slipped. The CNA attempted to lower the resident to the floor, but the resident sustained a left femur fracture. Documentation and staff interviews confirmed that the transfer was performed without the required second staff member, contrary to the resident's care plan and physician's orders. In the second incident, another resident, who was dependent on two staff for bed mobility due to cognitive impairment and physical limitations, was being rolled in bed by a single CNA during morning care. The CNA rolled the resident too far, causing the resident to fall out of bed from a height of approximately 18 inches. The resident sustained a laceration above the right eyebrow and forehead, which required sutures and further medical evaluation. The care plan, Kardex, and task documentation all indicated that two staff were required for bed mobility, but this was not followed. Both incidents were confirmed through facility documentation, clinical records, and staff interviews. The Director of Nursing and Nursing Home Administrator acknowledged that in both cases, staff failed to follow established care plans and physician orders requiring two-person assistance for transfers and bed mobility. These failures resulted in actual harm to the residents, including a femur fracture and a laceration requiring stitches.
Improper Transfer Results in Resident Fracture Due to Failure to Follow Two-Person Assist Policy
Penalty
Summary
A deficiency occurred when a resident, who had a history of left femur fracture, difficulty walking, atrial fibrillation, and asthma, was not transferred according to the facility's established policy and physician's orders. The resident's care plan and orders specified that transfers required the assistance of two staff members and, as needed, the use of a stand-up lift or walker. Despite these requirements, a CNA attempted to transfer the resident from a shower chair to a wheelchair with only one staff member present and placed towels under the resident's feet to keep them dry. During the transfer, the resident stepped off the towels, slipped, and fell to the floor. The CNA was able to support the resident's upper body and lower them to the ground, but the resident's lower body fell, resulting in significant pain and an inability to move the left leg. Assessment revealed the left lower extremity was bent and externally rotated, and the resident reported severe pain. The resident was subsequently sent to the emergency room, where a left hip/femur fracture was confirmed. Staff interviews and facility documentation confirmed that the CNA did not follow the resident's care plan or the facility's policy, which required two-person assistance for transfers. The incident was further corroborated by statements from other staff and the Director of Nursing, who verified that the transfer was performed improperly with only one staff member. This failure to follow established protocols directly resulted in actual harm to the resident.
Failure to Follow Physician's Orders for Catheter Care
Penalty
Summary
The facility failed to ensure that physician's orders were followed for a resident with a suprapubic catheter. The resident, who was admitted with diagnoses including anxiety, urinary retention, and bladder infections, had a physician's order dated 9/26/24, instructing staff not to change the suprapubic catheter. However, a nurse's note from 10/21/24 documented that a nurse attempted to change the catheter against these orders, removing the existing catheter and unsuccessfully attempting to insert a new one. This incident was confirmed during an interview with the Nursing Home Administrator and Director of Nursing on 11/09/24.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to acceptable infection control practices concerning Enhanced Barrier Precautions (EBP) during the care of a resident with a gastric tube. The facility's policy on Enhanced Barrier Precautions, implemented in April 2024, requires the use of gowns and gloves during high-contact resident care activities, especially for residents with indwelling medical devices like feeding tubes. However, during an observation of enteral tube feeding administration for a resident, it was noted that the LPN only wore gloves and did not use a gown, which is a requirement under EBP. Additionally, there was no signage indicating the need for EBP, nor was there any personal protective equipment (PPE) available outside the resident's room. The deficiency was confirmed through interviews with the LPN involved and the facility's Infection Preventionist, both acknowledging that EBP were not in place as required. The LPN admitted that both gloves and a gown should have been worn during the procedure, and the Infection Preventionist confirmed the absence of necessary precautions and PPE. This oversight indicates a failure to implement the facility's infection control policies effectively, particularly concerning residents with indwelling medical devices.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide a summary of the baseline care plan to three residents or their representatives within 48 hours of admission, as required by their policy. The policy mandates that a written summary of the baseline care plan, including goals and objectives, a summary of medications, dietary instructions, and treatments, be provided to the resident and/or their representative. However, for Residents R31, R103, and R105, there was no evidence that such summaries were shared. This was confirmed by a review of their clinical records and an interview with the Regional Nurse Consultant. Resident R31 was admitted with chronic obstructive pulmonary disease, hypertension, and heart failure, while Resident R103 had hypothyroidism, hypertension, and hyperlipidemia. Resident R105 was diagnosed with dementia, hypertension, and dysphagia. Despite these conditions, the facility did not provide the required baseline care plan summaries to these residents or their representatives, as evidenced by the lack of documentation in their clinical records and the confirmation from the Regional Nurse Consultant.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were consumed by Resident R55 during a medication administration review. The facility's policy on administering medications, dated 1/17/24, requires that medications be administered in a safe and timely manner, with staff remaining with the resident until each medication is swallowed. However, during an observation on 5/29/24, a medication cup filled with multiple unknown medications was found on Resident R55's bedside tray table without staff present. Resident R55, who has diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, and disorientation, stated that staff do not wait for them to take their pills because it takes a while. Further observations revealed a small white unknown medication on the floor in front of Resident R55's bedside tray table, and the LPN responsible for administering the medications was assisting other residents down the hallway. During an interview, Registered Nurse Employee E1 confirmed the presence of the medication cup on the bedside table and acknowledged that medications should not be left at the bedside and that the nurse should stay with the resident until the medications are ingested. This incident is a violation of the facility's medication administration policy and the relevant state codes for pharmacy and nursing services.
Failure to Discard Outdated Novolog Insulin
Penalty
Summary
The facility failed to appropriately discard outdated medications, specifically a vial of Novolog Insulin, on one of the three medication carts reviewed, namely the West A Hall medication cart. The facility's policy on administering medications, reviewed on 1/17/24, requires that the expiration or beyond-use date on the medication label be checked prior to administration, and that the date of opening be recorded on multi-dose containers. According to the manufacturer's guidelines for Novolog Insulin, a vial may be kept at temperatures below 30 degrees Celsius (86 degrees Fahrenheit) for up to 28 days after initial use. However, during an observation of drug storage on 5/30/24, a vial of Novolog Insulin with an open date of 4/10/24 was found, which exceeded the 28-day expiration period. During an interview conducted at the time of the observation, an LPN confirmed that the Novolog Insulin vial should have been discarded as it was beyond the 28-day period after opening, yet it remained in the medication cart for resident use. This oversight was in violation of the facility's policy and the manufacturer's guidelines, as well as state regulations regarding management, pharmacy services, and nursing services.
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.
