The Pines At Philadelphia Rehab And Healthcare Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 8410 Roosevelt Blvd, Philadelphia, Pennsylvania 19152
- CMS Provider Number
- 396070
- Inspections on file
- 25
- Latest survey
- July 21, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at The Pines At Philadelphia Rehab And Healthcare Ctr during CMS and state inspections, most recent first.
The facility did not report two separate incidents involving allegations of neglect and misappropriation: one where a resident's money was taken and another where a resident's biliary drain was forcibly removed during care, resulting in hospital transfer. In both cases, the facility conducted internal investigations but failed to notify the appropriate authorities as required.
A resident with chronic pain and other medical conditions did not receive scheduled doses of prescribed Xtampza ER for pain management due to a delay in pharmacy delivery. Despite a physician's order and facility policy requiring timely medication administration, the medication was not available or given as ordered, and the resident reported significant pain. The DON confirmed the delay and missed doses.
The facility failed to provide necessary grooming services for three residents, resulting in inadequate personal hygiene. A resident with mobility issues was observed with long facial hair and nails, expressing a desire for grooming. Another resident had not received a scheduled shower, and a third resident, dependent on assistance due to a stroke, also lacked grooming. These deficiencies were confirmed by staff.
The facility did not evaluate the competencies of three agency nursing staff members, including a registered nurse and a nursing aide, as required by its policy. Despite the facility's commitment to ongoing staff training and competency validation, these employees were not assessed for their skills or oriented to the facility's practices, as confirmed by interviews with the HR Director and DON.
Two residents with intact cognition were unaware of the arbitration agreements they signed upon admission. The facility's Admissions Director failed to educate them about their 30-day revocation rights, and the agreement improperly limited revocation to 10 days.
A resident with a diagnosis of anxiety did not receive necessary behavioral health care in an LTC facility. Despite documented anxiety and depression, the facility failed to implement interventions to address the resident's daytime anxiety. The resident experienced increased anxiety due to roommate changes, leading to trichotillomania, but no coping strategies were developed. Interviews confirmed the lack of interventions or documentation to manage the resident's anxiety.
The facility failed to store food according to professional standards, with unlabeled and expired items found in the refrigerator, freezer, and a resident's room. Observations included expired ketchup, unlabeled cheeses, and improperly labeled meats and spices. A resident had opened food items in their room without proper labeling or refrigeration.
The facility did not ensure complete and accurate physician orders for two residents. One resident's order for ProSource Nocarb lacked the route of administration, while another's order for Vancomycin HCL did not specify the appropriate diagnosis, only listing the drug class as IV ABT. These issues were confirmed by the DON during interviews.
A resident with multiple diagnoses, including dementia and a history of falling, experienced an unwitnessed fall and subsequent hip fracture. The facility failed to conduct a thorough investigation, did not interview key staff, and did not review camera footage. Pain management documentation was also incomplete.
Failure to Report Allegations of Neglect and Misappropriation
Penalty
Summary
The facility failed to report allegations of neglect and misappropriation of resident property for two residents, as required by federal and state law. In the first case, a resident reported that money was missing from his nightstand, and although the facility conducted an internal investigation—including reviewing security footage and interviewing staff and residents, ultimately identifying and terminating a perpetrator—the incident was not reported to the appropriate authorities. Facility policy requires that such incidents be reported, but this step was omitted. In the second case, a resident with a history of acute cholecystitis and a biliary drain reported that, during care provided by two staff members, her biliary drain was forcibly removed, resulting in a hospital transfer for replacement of the drain. The resident was cognitively intact at the time of the incident and reported the event to the social services department. Despite the seriousness of the allegation and the resulting harm, the facility did not report the incident as required. Interviews with facility leadership confirmed the failure to report both incidents.
Failure to Timely Administer Prescribed Pain Medication Due to Pharmacy Delay
Penalty
Summary
The facility failed to ensure the timely acquisition and administration of a prescribed pain medication for one resident who was admitted with diagnoses including muscle wasting and atrophy, COPD, and chronic pain syndrome. Despite a physician's order for Xtampza ER, an extended-release oxycodone for pain management, the medication was not administered at the scheduled times from the evening of admission through several subsequent scheduled doses. The resident, who was cognitively intact, reported not receiving the medication and experiencing significant pain, rating it as 8.5 out of 10. Facility policy required pharmacy services to be available 24/7 and for nursing staff to ensure residents have a sufficient supply of prescribed medications, including timely communication with the pharmacy if medications are unavailable. Documentation and interviews confirmed that the resident did not receive the ordered pain medication due to a delay in delivery from the pharmacy, resulting in unmet pain management needs.
Failure to Provide Adequate Grooming Services
Penalty
Summary
The facility failed to provide necessary grooming services for three residents, resulting in inadequate personal hygiene. Resident R11, who required substantial assistance with personal hygiene due to a fracture and joint surgery, was observed with long facial hair and nails. The resident expressed a desire to be shaved and have her nails cut, indicating a lack of grooming services. This observation was confirmed by the Director of Nursing. Resident R95, admitted with reduced mobility and chronic obstructive pulmonary disease, required limited assistance with personal care. The resident had long nails and facial hair and had not received a shower since admission, despite being scheduled for showers twice a week. The lack of documentation on whether the shower was provided or refused was confirmed by the Director of Nursing. Similarly, Resident R22, who was dependent on assistance for personal hygiene due to the effects of a stroke, was observed with long nails and facial hair, expressing a desire for grooming. These observations were confirmed by a nursing aide.
Failure to Evaluate Competency of Agency Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff possessed the required skills to properly care for residents' needs, as evidenced by the review of personnel files and interviews with staff. Specifically, the facility did not evaluate the competencies of three agency employees, identified as a registered licensed nurse, a nursing aide licensed nurse, and a licensed nurse, who were hired to work at the facility. The facility's policy on staff training emphasizes the importance of ongoing staff training and competency validation, yet these employees were not assessed for their competencies in their specific job duties and responsibilities. Interviews with the Human Resource Director and the Director of Nursing confirmed that these agency staff members were not evaluated for their competencies or oriented to the facility's practices, which is a requirement under the facility's policy and state regulations.
Failure to Ensure Resident Understanding of Arbitration Agreement
Penalty
Summary
The facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement. This deficiency was identified for two residents, both of whom had a Brief Interview for Mental Status (BIMS) score of 15, indicating they were cognitively intact. Despite this, both residents reported being unaware of the arbitration agreement they signed upon admission. Resident R11, admitted with diagnoses of fracture and orthopedic aftercare, signed the agreement on August 30, 2024, but later stated they had never heard of it and did not understand the procedures. Similarly, Resident R38, who signed the agreement on August 26, 2024, recalled signing something upon admission but did not understand the arbitration procedure. The facility's process for educating residents about the arbitration agreement was inadequate. The Admissions Director, responsible for this education, admitted to not informing residents about their 30-day right to revoke the agreement, as she was unaware of this requirement. The facility's arbitration agreement limited residents to a 10-day revocation period, contrary to the standard 30 days. This oversight in resident education and the improper revocation period contributed to the deficiency identified by the surveyors.
Failure to Provide Behavioral Health Care for Resident with Anxiety
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as Resident 38, who was admitted with a diagnosis of anxiety. The resident's social service assessment indicated feelings of depression for a significant period, and subsequent progress notes documented anxiety related to personal issues. Despite these documented concerns, the facility did not implement any interventions to address the resident's anxiety during the day. The only treatment provided was a prescription for Mirtazapine for insomnia, which did not address the resident's daytime anxiety. Interviews with the resident revealed that changes in roommates exacerbated her anxiety, leading to symptoms of trichotillomania. The resident expressed that coloring helped her calm down, yet no interventions were developed to assist her in coping with anxiety. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed the absence of any interventions or documentation to manage the resident's anxiety or promote her well-being, resulting in a deficiency in providing necessary behavioral health care.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that food stored in the refrigerator, freezer, and resident's room was maintained according to professional standards for food service safety. During an initial tour of the Food Service Department, several deficiencies were observed. In the main walking refrigerator, there was an open ketchup bottle that had expired, two cheeses without labels, and various meats and sausages that were either unlabeled or lacked expiration dates. Additionally, the main freezer contained opened home fries and veggie burgers that were not labeled. At the serving table of the prep line, various spices and sauces were found with only received dates and no expiration dates, and some spices were expired. Furthermore, an interview with a resident revealed that they had opened salsa, nacho cheese, ranch, and two opened pickle jars in their room without proper labeling or refrigeration. A nursing aide confirmed these observations. These findings indicate a failure to adhere to the facility's policy on labeling and dating food items, which requires all fresh and frozen foods to be dated with the date they were received unless they have a purveyor shipping label. The policy also specifies the duration for which certain refrigerated items can be kept once opened.
Incomplete Physician Orders for Two Residents
Penalty
Summary
The facility failed to ensure that physician orders were recorded completely and accurately for two residents. For the first resident, who was admitted with diagnoses including anemia, malnutrition, and dependence on renal dialysis, the physician's order for ProSource Nocarb did not include the route of administration. This omission was confirmed by the Director of Nursing during an interview. For the second resident, admitted with diagnoses including MRSA and long-term use of antibiotics, the physician's order for Vancomycin HCL did not specify the appropriate diagnosis for the medication, only indicating the class of drug as IV ABT. This was also confirmed by the Director of Nursing during an interview. These deficiencies were identified during a clinical record review and staff interviews.
Incomplete Investigation of Resident's Hip Fracture
Penalty
Summary
The facility failed to conduct a complete and thorough investigation regarding a hip fracture for a resident (CL1). The resident, who was admitted with multiple diagnoses including dementia and a history of falling, experienced an unwitnessed fall shortly after admission. Despite initial assessments and pain management attempts, the resident continued to complain of increasing pain over several days, culminating in a diagnosis of a hip fracture after being transferred to a hospital. There was a significant gap in pain management documentation, with no pain assessment or treatment recorded for nearly 12 hours on one of the days leading up to the hospital transfer. The facility's policies on abuse prevention and incident investigation were not followed. The investigation into the resident's injury was incomplete, as key staff members who were on duty during the relevant periods were not interviewed. Additionally, the facility did not review camera footage to determine if the resident had any unwitnessed falls between the initial fall and the hospital transfer. The investigation was left inconclusive as the facility awaited the resident's return from the hospital. Interviews with the Director of Nursing and the Administrator confirmed the deficiencies in the investigation process. The facility did not adhere to its own protocols for investigating injuries of unknown origin, which resulted in a failure to identify the cause of the resident's hip fracture. This lack of thorough investigation and documentation was confirmed by the surveyors, leading to the identification of the deficiency.
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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