Southeastern Pennsylvania Veteran's Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Spring City, Pennsylvania.
- Location
- One Veterans Drive, Spring City, Pennsylvania 19475
- CMS Provider Number
- 39A435
- Inspections on file
- 23
- Latest survey
- October 7, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Southeastern Pennsylvania Veteran's Center during CMS and state inspections, most recent first.
A nurse administered another resident's medications to a cognitively intact resident with multiple chronic conditions after only verbally confirming the last name, without using other required identification methods. The resident developed symptoms including nausea, vomiting, and near syncope, requiring hospital admission for observation and treatment of medication side effects.
A resident with hemiplegia and hemiparesis, dependent on two-person assistance for bed mobility, was left in the care of a single staff member during incontinence care. The staff member did not follow the care plan, and while distracted, the resident fell from a high bed, sustaining multiple serious injuries including cervical fractures and a subdural hematoma.
A resident with diabetes and peripheral vascular disease sustained a second-degree burn after a nurse, who had not been educated on the facility's safe food heating policy, failed to check the temperature of reheated ramen soup before serving it. The incident occurred when the resident spilled the overheated soup on their chest, and documentation confirmed that required temperature checks were not performed. The Nursing Home Administrator acknowledged that direct care staff had not been trained on the safe food heating procedure, leading to an Immediate Jeopardy situation.
The Commandant and DON did not ensure that all direct care staff received education and training on safe heating and reheating of food and beverages, as required by facility policy and state regulations. This lack of training placed residents in Immediate Jeopardy due to the risk of burns from improperly handled food and beverages.
A resident with heart failure and kidney disease experienced a significant weight gain over five days, but was not reweighed or assessed promptly, and the physician was not notified until several days after the change was identified, contrary to facility policy.
A resident with multiple chronic conditions did not receive care in accordance with physician orders, as staff failed to enforce a prescribed fluid restriction and administered Midodrine despite blood pressure readings above the ordered threshold. These lapses were confirmed by facility leadership and documented through clinical record review.
A resident with ESRD who attended dialysis missed multiple scheduled doses of Renvela because they were out of the facility during medication times. The missed doses were documented as 'resident unavailable,' and the physician was not notified of these omissions. The DON confirmed the medication was not given due to the resident's absence for dialysis and that the physician was not informed.
A resident returned from the hospital with a Foley catheter and instructions for a void trial, but the facility failed to assess the catheter's necessity or conduct the trial. Despite documented catheter care, the resident developed a UTI, which was diagnosed after being sent to the hospital for hyponatremia. The facility did not complete the required observation form upon readmission.
A resident admitted with a cancer diagnosis did not receive a timely oncology consultation. Despite being assessed by a CRNP and having a liver biopsy and oncology appointment scheduled, there was no documented evidence of an oncologist's assessment or identified treatment course. This was confirmed by the DON.
Significant Medication Error Resulting in Hospitalization
Penalty
Summary
A significant medication error occurred when a licensed nurse administered another resident's medications to a resident with diagnoses including diabetes, hypertension, prostate cancer, and congestive heart failure. The nurse, who was not the resident's regular caregiver, entered the room where multiple residents were present. Upon calling out the resident's last name, the resident responded, and the nurse proceeded to give the medications without further verification. The medications administered included several drugs not prescribed to the resident, such as Bisacodyl, Chlorpromazine, Diltiazem, Duloxetine, Loratadine, Oxybutynin, Pantoprazole, Senna Plus, Tramadol, and Vraylar. Following the administration, the resident initially denied any immediate ill effects but was later reported by family to be pale, nauseated, and had vomited. The resident's vital signs were assessed, and after further symptoms developed, the physician was notified and ordered the resident to be transferred to the hospital. Hospital records indicated the resident was admitted for observation due to medication side effects, including near syncope, nausea, vomiting, and transient bradycardia, likely related to the medications received in error. The facility's policy required verification of resident identity using multiple methods, such as checking identification bands, reviewing photographs, and confirming with other staff if necessary. However, these procedures were not fully followed during the medication pass, leading to the error. The incident was documented in nursing progress notes and confirmed through staff statements and facility investigation records.
Failure to Follow Two-Person Assist Care Plan Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with hemiplegia and hemiparesis following a cerebral infarction, who required two-person assistance for bed mobility, was left in the care of a single non-licensed staff member during incontinence care. The resident's care plan and Minimum Data Set (MDS) both specified the need for two staff members to assist with bed mobility, but this protocol was not followed. During the care, the staff member attempted to manage soiled linens and clean the resident alone, despite the resident's repeated attempts to roll and complaints of hip pain. While the staff member was distracted by picking up a sheet that had fallen to the floor, the resident rolled off the bed and fell onto the floor. The bed was in a high position at the time to facilitate incontinence care. The fall resulted in significant injuries, including a closed displaced fracture of the first and second cervical vertebrae, a cervical compression fracture, a subdural hematoma, and a scalp laceration, all of which required hospitalization. Facility documentation and interviews confirmed that the staff member did not follow the resident's care plan, which mandated two-person assistance for bed mobility. The incident was substantiated as neglect, as the failure to provide the required level of assistance directly led to the resident's injuries.
Failure to Educate Staff on Safe Food Heating Results in Resident Burn
Penalty
Summary
The facility failed to ensure that direct care staff were educated on the safe process for heating and reheating food, as required by facility policy. The policy specified that food and beverages must be heated, stirred, temperature-checked, stirred again, and re-checked before being served to residents, with temperatures maintained between 140°F and 165°F to minimize the risk of burns. However, a licensed nurse who had not received this education prepared instant ramen soup for a resident and did not check the temperature before serving it. The resident involved had diagnoses of diabetes and peripheral vascular disease, was cognitively intact, and required set-up assistance with feeding. After the soup was served, the resident spilled it on their chest, resulting in a second-degree burn. Observations and clinical documentation confirmed the presence of a significant burn area on the resident's chest and abdomen, and the resident reported pain following the incident. Progress notes and wound care consults documented the extent and treatment of the burn. Interviews and facility documentation revealed that the nurse did not follow the required procedure for checking food temperature, and there was no evidence of temperature documentation for the soup. The Nursing Home Administrator confirmed that the staff member had not been trained on the safe food heating policy, and further acknowledged that all direct care staff, including nurses and nursing assistants, had not received this education. This lack of staff education and failure to follow policy led to an Immediate Jeopardy situation when the resident sustained a burn from overheated food.
Removal Plan
- Education was provided to the staff
- A whole house audit was conducted to check all microwaves in the facility had thermometers attached to it
- All residents were assessed to ensure no other residents received a burn from re-heated food items
- Process signage for re-heating food in the microwave were attached to the microwaves
- House-wide education developed and implemented for all facility staff on re-heating process, education was implemented and presented during the new hire and agency orientation
- Dietary performed audits to ensure thermometers are present and functioning on all microwaves in resident areas
- Audits were completed and ongoing
- The outcome of audits will be reviewed at the QA meeting
Failure to Train Staff on Safe Food and Beverage Heating Procedures
Penalty
Summary
The facility failed to ensure that all direct care staff were properly educated and trained on the facility's policy and procedure regarding the safe heating and reheating of food and beverages. This failure was attributed to the inactions of the Commandant and the Director of Nursing (DON), who did not fulfill their job responsibilities to manage and control health-related activities and ensure a safe environment for residents and staff. The Commandant was responsible for operating safety programs in accordance with agency, state, and federal standards, while the DON was responsible for communicating and ensuring understanding and implementation of facility policies and procedures among nursing staff. A review of job descriptions and clinical records revealed that the Commandant and DON did not provide the necessary education and training to direct care staff on safe food and beverage heating practices. As a result, residents were placed in Immediate Jeopardy due to the risk of burns from improperly heated food and beverages. The report cites specific state regulations that were not followed, highlighting the failure of facility management to ensure compliance with required safety and training standards.
Failure to Timely Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to timely notify a physician of a significant weight change in a resident with diagnoses of congestive heart failure and chronic kidney disease. According to the facility's policy, significant weight changes require prompt reweighing and physician notification. The resident had a physician's order to be weighed three times a week to monitor for weight gain due to edema. A review of the resident's records showed a 20-pound (9.22%) weight gain over five days, but the resident was not reweighed until five days after this significant change was identified. Additionally, there was no documentation that the resident was assessed upon identification of the significant weight gain, nor was there evidence that the physician was notified until several days later. The Director of Nursing confirmed that the physician was not notified in a timely manner regarding the resident's significant weight gain, which was contrary to facility policy and regulatory requirements.
Failure to Follow Physician Orders for Fluid Restriction and Medication Administration
Penalty
Summary
The facility failed to follow physician orders regarding fluid restriction and medication administration for a resident with multiple diagnoses, including congestive heart failure, diabetes mellitus, urinary retention, and chronic obstructive pulmonary disease. The physician had ordered a strict 2000 cc fluid restriction, with specific allocations for dietary and nursing shifts. However, clinical record review showed that on multiple dates, the resident's fluid intake exceeded the ordered restriction, with daily totals ranging from 2090 cc to 2960 cc, surpassing the prescribed limit on numerous occasions. Additionally, the facility did not adhere to the physician's order for the administration of Midodrine, a medication intended to be held if the resident's systolic blood pressure was greater than 120 mmHg. Medication administration records revealed that the resident received Midodrine on several occasions when their systolic blood pressure was above the specified threshold. These findings were confirmed during interviews with the Nursing Home Administrator and Director of Nursing, who acknowledged that physician orders for both fluid restriction and medication administration were not being followed for this resident.
Failure to Administer Ordered Medication and Notify Physician for Dialysis Resident
Penalty
Summary
A resident with End Stage Renal Disease (ESRD) who attends dialysis three times weekly had a physician's order for Renvela 800 mg, to be administered two tablets three times daily at 8:00 a.m., 12 noon, and 5:00 p.m. Review of the Medication Administration Record for April 2025 showed that the 12 noon dose of Renvela was not administered on multiple dates, with documentation indicating the resident was unavailable due to being out of the facility for dialysis. There was no evidence in the clinical records that the resident's physician was notified about the missed doses. The Director of Nursing confirmed that the medication was not given because the resident was at dialysis and that the physician was not informed of the missed administrations. The facility failed to ensure that ordered medications were administered as prescribed to a resident receiving dialysis, and did not notify the physician when doses were missed.
Failure to Assess Catheter Necessity Leads to UTI
Penalty
Summary
The facility failed to timely assess the need for an indwelling urinary catheter for a resident who was readmitted from the hospital. The resident, who had been hospitalized for a fractured hip, returned to the facility with a Foley catheter and instructions to conduct a void trial as ambulation improved. However, the facility did not complete the required Indwelling Catheter Observation Form upon the resident's readmission, nor did they attempt the void trial as instructed. The resident's clinical record indicated that catheter care was documented every shift, but there were signs of potential complications, such as cloudy urine with sediment and confusion, which were noted in the progress notes. Despite these observations, the catheter remained in place until the resident was sent to the hospital for hyponatremia and was subsequently diagnosed with a UTI. The facility's failure to assess the necessity of the catheter and to follow the hospital's discharge instructions contributed to the resident's condition.
Failure to Ensure Timely Oncology Consultation
Penalty
Summary
Southeastern Pennsylvania Veterans' Center failed to ensure timely oncology consultation for one of the 24 residents reviewed. The resident was admitted in November 2023 with a diagnosis of cancer. A Certified Registered Nurse Practitioner assessed the resident on November 2, 2023, noting the cancer diagnosis. A liver biopsy was scheduled for January 31, 2024, and an oncology appointment was scheduled for February 23, 2024. However, the clinical record did not show any documented evidence that the resident's cancer was assessed by an oncologist or that a course of treatment was identified. This information was confirmed by the Director of Nursing during an interview on March 14, 2024.
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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