Titusville Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Titusville, Pennsylvania.
- Location
- 81 Dillon Drive, Titusville, Pennsylvania 16354
- CMS Provider Number
- 395901
- Inspections on file
- 17
- Latest survey
- June 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Titusville Nursing And Rehab during CMS and state inspections, most recent first.
Open vials of Tubersol were found in two medication rooms, one without an open date and another past the discard period, and an LPN left a medication cart unlocked and unattended with medications on top while obtaining milk for a resident, contrary to facility policy.
Two residents with complex medical conditions did not receive their evening medications at their preferred or scheduled times, with doses administered over an hour late on multiple occasions by an LPN. Both residents expressed dissatisfaction with the late administration, and the Infection Control Preventionist confirmed the deviations from policy and resident preference.
A resident with COPD, diabetes, and acute respiratory failure was observed receiving supplemental oxygen at 8.5 L/min via nasal cannula, despite a physician's order for 6 L/min. Facility staff, including the DON, confirmed the oxygen was not set according to the order.
A resident with paraplegia, multiple stage four pressure ulcers, and a urinary catheter did not receive wound care in accordance with infection control protocols. An LPN failed to don a gown and did not perform hand hygiene between removing a soiled dressing and cleansing the wound, despite facility policies requiring these steps for residents with MDROs and indwelling catheters. These lapses were confirmed through observation and staff interviews.
The facility failed to timely notify a physician and begin treatment for a resident's condition change, resulting in an 86-hour delay in administering medication for oral thrush. Additionally, the facility did not obtain a physician's order for an abductor pillow for another resident, leading to inconsistent use and discomfort. Staff interviews confirmed the absence of necessary documentation and care plans.
A resident with a history of femur fracture, hypertension, and diabetes was observed with their nasal cannula improperly stored on the floor, contrary to facility policy requiring it to be kept in a plastic bag when not in use. The DON confirmed the deficiency, highlighting a failure in maintaining proper respiratory care.
A facility failed to document a clinical rationale and duration for the continued use of a PRN psychotropic medication beyond 14 days for a resident with anxiety, COPD, and heart failure. The resident received Vistaril beyond the 14-day limit without the necessary documentation, as confirmed by the DON. This oversight violated the facility's policy on psychotropic medication use.
The facility did not secure medication cart and room keys on Unit B. Facility policies require that medication carts be secured during medication pass and that medication rooms, carts, and supplies be locked or attended by authorized personnel. However, a nurse left the keys unsecured on a resident's bed. The DON confirmed the keys were for the medication cart and room and should be secured at all times.
The facility did not ensure the Infection Preventionist attended two out of four required QAPI Committee meetings between July and December 2023. The facility's policy mandates the Infection Control Representative's presence at these meetings, but attendance records showed no evidence of their participation. This was confirmed by the Nursing Home Administrator.
The facility did not ensure the designated Infection Preventionist (IP) attended Infection Control Committee meetings or worked part-time focusing solely on infection control. The Director of Nursing (DON) served as the IP from November 2023 to May 2024 but could not provide evidence of additional part-time hours dedicated to infection control. A review of meetings from July 2023 to December 2023 showed no IP attendance.
Failure to Discard Outdated Medications and Secure Medication Cart
Penalty
Summary
The facility failed to properly manage and secure medications in accordance with its own policies and professional standards. In two medication rooms, open vials of Tubersol were found either without an open date or with an open date that exceeded the manufacturer's recommended discard period. Specifically, one vial lacked any indication of when it was opened, making it impossible for staff to determine if it was still safe for use, while another vial was observed to have been open beyond the 30-day discard period. Staff interviews confirmed that these vials should have been discarded and that the facility's policy required proper labeling and timely disposal of multi-use vials. Additionally, a medication cart was observed left unlocked and unattended in a hallway while an LPN went into a pantry to obtain a glass of milk for a resident. Medications were left on top of the cart, and the cart was not within the LPN's line of sight during this time. The LPN confirmed that the cart should have been locked and that medications should not have been left unsecured or out of view, as per facility policy. These actions resulted in the potential for unauthorized access to medications.
Failure to Honor Resident Choice in Medication Administration Timing
Penalty
Summary
The facility failed to honor and facilitate resident self-determination by not supporting resident choices regarding the timing of medication administration for two residents. According to facility policy, medications are to be administered within 60 minutes of the scheduled time. However, both residents reported receiving their evening medications significantly later than their preferred and scheduled time of 8:00 p.m. Specifically, one resident received seven medications at 9:25 p.m. on one occasion, and the other resident received five medications at 9:06 p.m. and 9:24 p.m. on two separate occasions. Both residents expressed dissatisfaction with the late administration and indicated a preference for receiving their medications closer to 8:00 p.m. Clinical records confirmed the late administration of medications, and interviews with the residents corroborated these findings. The Infection Control Preventionist also confirmed that the medications were not administered in a timely manner and not in accordance with the residents' stated preferences. The affected residents had medical conditions including diabetes, anxiety, chronic obstructive pulmonary disease, protein-calorie malnutrition, and bipolar disorder, which may require consistent medication timing. The failure to administer medications as scheduled and according to resident preference constituted a violation of resident rights and facility policy.
Failure to Administer Oxygen at Ordered Flow Rate
Penalty
Summary
The facility failed to provide oxygen therapy according to the physician's orders for one resident. Facility policy required staff to review the physician's order and administer oxygen at the prescribed flow rate. The resident, who had diagnoses including chronic obstructive pulmonary disease, diabetes, and acute respiratory failure, had a physician's order for oxygen at 6 liters per minute via nasal cannula. However, multiple observations on the same day showed the resident receiving oxygen at 8.5 liters per minute. The Director of Nursing confirmed that the oxygen was not set according to the physician's order.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols during a dressing change for a resident with multiple stage four pressure ulcers and a urinary catheter. Specifically, a Licensed Practical Nurse (LPN) entered the resident's room without donning a gown, as required by the facility's Enhanced Barrier Precautions (EBP) policy for residents with multi-drug resistant organisms (MDRO) and indwelling catheters. The LPN proceeded to remove the soiled dressing and cleanse the wound without performing hand hygiene between steps, contrary to the facility's wound care policy. The resident involved had a history of paraplegia and multiple stage four pressure ulcers, as well as an MDRO and a urinary catheter, necessitating strict adherence to EBP. The LPN's failure to don appropriate personal protective equipment and perform hand hygiene was confirmed during interviews with both the LPN and the Infection Control Preventionist. These actions were observed and documented during a wound care procedure, and the facility's policies clearly outlined the required infection control measures that were not followed.
Delayed Treatment and Lack of Physician's Order for Assistive Device
Penalty
Summary
The facility failed to notify the physician and begin treatment in a timely manner for a change in a resident's condition, specifically for Resident R4. Resident R4, who was admitted with diagnoses including dementia, atrial fibrillation, and type II diabetes, exhibited white patches in the mouth on 7/20/24. Instead of calling the physician, the nursing staff faxed the information, leading to a delay in receiving a treatment order for Nystatin Mouth/Throat Suspension, which was not administered until 7/24/24, approximately 86 hours after the initial observation. The Director of Nursing confirmed the delay in treatment and acknowledged that the nursing staff should have contacted the physician directly. Additionally, the facility failed to obtain a physician's order or clarification for the use of an assistive device for Resident R25, who had a history of a right hip fracture and repair. The clinical record lacked evidence of a physician's order for an abductor pillow, which was inconsistently used and reportedly caused pain to the resident. Interviews with staff confirmed the absence of a care plan or nurse aide tasks for the pillow's use, and the Therapy Director noted that the pillow was not the appropriate size for the resident. The Corporate Nurse Consultant also confirmed the lack of documentation for the pillow's use.
Improper Respiratory Equipment Care for a Resident
Penalty
Summary
The facility failed to maintain proper care of respiratory equipment for a resident, identified as Resident R210, who was reviewed for respiratory care. The facility's policy on infection control related to oxygen administration requires that the oxygen cannula and tubing used as needed (PRN) be kept in a plastic bag when not in use. However, observations revealed that Resident R210's nasal cannula was not stored properly. Instead, the oxygen tubing was connected to the oxygen concentrator, and the prongs that go into the nostrils were found laying on the floor on multiple occasions. Resident R210's clinical record indicated an admission with diagnoses including a fracture of the right femur, hypertension, and diabetes. Physician orders dated 7/12/24 specified providing oxygen at 2 liters per minute via nasal cannula. Despite these orders, the nasal cannula was observed on the floor on 7/22/24 and 7/23/24, with a piece of tape wrapped around the tubing dated 7/17/24. The Director of Nursing confirmed during an interview that the nasal cannula should not be on the floor and should be placed in a bag when not in use, indicating a failure to adhere to the facility's infection control policy.
Failure to Document Clinical Rationale for Extended PRN Psychotropic Use
Penalty
Summary
The facility failed to adhere to its policy regarding the administration of PRN psychotropic medications, specifically for a resident identified as R6. The policy mandates that PRN orders for psychotropic medications are limited to 14 days unless a clinical rationale and duration for continued use are documented by the prescriber. However, the facility did not provide a clinical rationale or specify a duration for the continued use of Vistaril, an anti-anxiety medication, beyond the initial 14-day period. This oversight was identified during a review of Resident R6's Medication Administration Record (MAR), which showed that the PRN Vistaril order was revised multiple times without including the necessary documentation for extending its use. Resident R6, who was admitted with diagnoses including chronic obstructive pulmonary disease, anxiety, and heart failure, received PRN Vistaril on several occasions beyond the 14-day limit set by the original order. The Director of Nursing confirmed that the PRN Vistaril order lacked the required stop date and clinical rationale for its continued use beyond 14 days. This deficiency was identified during a survey, highlighting a failure in the facility's adherence to its own resident care policies and nursing services regulations.
Unsecured Medication Keys on Unit B
Penalty
Summary
The facility failed to ensure the security of medication cart and medication room keys on Unit B. According to the facility's policies, the medication cart should be secured during medication pass, and medication rooms, carts, and supplies should be locked or attended by authorized personnel. However, during an observation, it was found that the nurse's medication cart and medication room keys were left unsecured on a resident's bed. The Director of Nursing confirmed that these keys were for the medication cart and room on Unit B and acknowledged that they should be secured at all times and not left in a resident's room.
Infection Preventionist Absence from QAPI Meetings
Penalty
Summary
The facility failed to ensure the required attendance of the Infection Preventionist at the Quality Assurance and Performance Improvement (QAPI) Committee meetings for two out of four quarterly meetings between July 2023 and December 2023. According to the facility's policy, the Infection Control Representative is mandated to serve on the QAPI Committee, which is scheduled to meet monthly. However, a review of the QAPI Committee Attendance Records for the specified period showed no evidence of the Infection Preventionist's attendance at the required meetings. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the absence of the Infection Preventionist from the meetings as required by the facility's policy.
Infection Preventionist Attendance and Role Deficiency
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) attended the Infection Control Committee meetings and worked at the facility focusing solely on infection control at least part-time, as required. The Director of Nursing (DON) was assigned the role of the IP from November 2023 through May 2024. However, the DON, who works full-time, could not provide evidence of completing additional part-time hours dedicated to infection control beyond their full-time duties. Furthermore, a review of the Infection Control Committee meetings from July 2023 through December 2023 showed no attendance or sign-in by an IP. During an interview, the Nursing Home Administrator confirmed the absence of evidence showing an IP's attendance at the meetings during the specified period. The DON also confirmed the lack of proof for completing additional part-time hours focused on infection control.
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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