Twinbrook Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Erie, Pennsylvania.
- Location
- 3805 Field Street, Erie, Pennsylvania 16511
- CMS Provider Number
- 395041
- Inspections on file
- 28
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Twinbrook Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to follow its own policies for meal supervision, nutritional assessment, and implementation of dietary interventions. A resident with CVA, hemiplegia, dysphagia, and a history of pocketing food, who was care planned to need supervision with eating, was observed eating lunch without staff present, and the speech therapist confirmed supervision was required. Several residents with conditions such as muscle wasting, morbid obesity, diabetes, heart failure, and respiratory failure experienced notable weight loss without documented comprehensive nutritional assessments after earlier dates or after admission as required. In addition, when an RD documented significant recent weight loss for a resident and recommended a reweigh, there was no evidence the reweigh occurred, and when another resident’s assessment called for adding a House Shake at dinner due to unplanned significant weight loss, there was no documentation that this supplement was added to the meal plan or orders.
The facility failed to promptly notify a physician of an abnormal potassium lab result for a resident with Alzheimer's disease, atrial flutter, muscle weakness, and hypertension. A lab specimen showed an abnormal potassium level, but documentation showed the result was not reviewed with the physician until weeks later, at which time the resident was transferred to the hospital. The facility's own policy required prompt notification of changes in a resident's condition, and the ADON confirmed there was no evidence of timely physician notification.
Surveyors observed that the facility did not maintain a sanitary, orderly, and homelike environment on two nursing units, noting brown-stained ceiling tiles in a secured unit hallway and in the East 1 resident lounge, as well as broken or missing baseboard registers in two resident rooms. These environmental issues were confirmed by the DON during the survey.
The facility did not post the required daily nurse staffing information. During an observation, surveyors were unable to locate any publicly displayed staffing posting, and the DON confirmed that the required information was not posted, resulting in a deficiency related to the licensee’s responsibilities.
On one occasion, insufficient nursing staff led to significant delays in administering medications and starting enteral feedings for three residents. Only one nurse was available during a shift, resulting in delayed care, as confirmed by staff interviews and facility records.
Surveyors found that the facility did not maintain required dishwashing machine rinse temperatures, with observed readings below the manufacturer's minimum standard. Additionally, temperature logs for the evening shift were not completed for an entire month, and staff did not consistently document or report temperature deficiencies as required.
Staff did not follow infection control protocols for Enhanced Barrier Precautions (EBP), including failing to use required PPE and perform hand hygiene during wound care for a resident with a chronic pressure ulcer. PPE was not available for residents needing EBP, and an LPN was observed handling medications with contaminated gloves after touching multiple surfaces. Staff interviews confirmed these lapses in infection control practices.
A resident with dementia and other medical conditions did not have a properly completed POLST form or documentation of advance directive wishes in their record. The only order present was for Full Code (CPR), and there was no evidence that the resident or their representative had been provided information or assistance regarding advance directives. A nurse confirmed the POLST was incomplete and not signed by a physician, resulting in inconsistent documentation of the resident's life-sustaining treatment preferences.
Surveyors observed that three resident rooms were not maintained in a clean and sanitary condition, with black substances and peeling paint on walls, and a bathroom sink that was not draining, causing a resident to use another room for personal hygiene. The Maintenance Director confirmed these issues, which were inconsistent with facility policy requiring a safe and homelike environment.
The facility did not provide written summaries of the baseline care plan and order summary to two residents with complex medical conditions, nor to their representatives, within the required timeframe after admission. This was confirmed by a registered nurse and was not documented in the residents' clinical records.
A resident with diabetes, paraplegia, and hypertension had physician orders and therapy recommendations for the use of a resting hand splint/palm roll splint to manage contractures, but no care plan was developed to address this intervention. The Therapy Director confirmed the omission of the required care plan.
A resident with diabetes, paraplegia, and hypertension, who required a palm roll splint for contracture management per physician's orders, was repeatedly observed without the splint applied as directed. Documentation did not show evidence of the splint being used as ordered, and the DON confirmed the resident was not receiving the prescribed intervention.
Surveyors found that multiple medication carts and a medication room contained open insulin pens and vials, as well as a Tubersol vial, that were either not labeled with open dates or kept past their recommended discard dates. LPNs confirmed that these medications should have been discarded according to facility policy and manufacturer guidelines.
The facility did not ensure that the DON worked full-time in the building, as required. Instead, the DON was assigned to work as a charge nurse and floor nurse on several days, which did not fulfill the full-time DON responsibilities.
Required daily nurse staffing information was not posted in a publicly accessible area, as confirmed by observation and interview with the DON.
The facility failed to follow physician's orders for lab tests for three residents, resulting in missed or delayed blood draws. A resident with COPD and respiratory failure had a CBC drawn late and a CMP not drawn at all. Another resident with COPD and dementia missed routine potassium level checks, and a third resident with diabetes did not have ordered CMP and CBC tests collected. The DON confirmed these lapses.
The facility failed to provide timely and accurate laboratory services due to an unorganized system and insufficient supplies, affecting four residents. Orders for various blood tests were not completed as required, and the laboratory binder contained incomplete documentation. The DON confirmed these issues, highlighting the facility's inability to meet residents' laboratory needs.
A facility failed to maintain a homelike environment for a resident when the baseboard heating system in their room was found detaching from the wall, creating a noticeable gap. This issue was observed during a survey, and the DON confirmed that it was not homelike and should have been addressed, as per the facility's policy requiring maintenance to ensure a comfortable environment.
The facility failed to ensure timely physician documentation for six residents, with progress notes delayed beyond the required timeframe. Residents had various medical conditions, including dementia, Alzheimer's, and diabetes. The DON confirmed the delays, which ranged from 27 to 51 days.
The facility failed to develop comprehensive care plans for four residents regarding supplemental oxygen use. Despite physician orders, the care plans lacked specific interventions to guide staff, as confirmed by the Assistant Director of Nursing. This deficiency affected residents with conditions like heart disease, COPD, and respiratory failure.
The facility failed to update care plans for three residents to reflect current care and services. One resident's care plan did not address a CPAP requirement, another's was not updated for pain management, and a third's did not reflect the correct oxygen order. The DON confirmed these deficiencies.
The facility failed to maintain cleanliness and prevent infection spread in respiratory care equipment for six residents. Observations showed outdated oxygen tubing and dirty concentrator filters, contrary to the facility's policy. A CPAP mask was also found on the floor without a barrier. The DON confirmed these issues, indicating non-compliance with physician orders.
The facility failed to maintain privacy and dignity for two residents by not covering their urinary catheter drainage bags, as required by facility policy. Observations showed the bags were visible from the hallway, and the DON confirmed the lack of privacy covers.
A facility failed to provide a written summary of the baseline care plan and order summary to a resident with chronic respiratory failure, pneumonia, and epileptic seizures within 48 hours of admission. The facility's policy requires this summary to include initial goals, medications, dietary instructions, and services to be provided. The DON confirmed the absence of this documentation in the resident's clinical record.
A facility failed to provide appropriate pain management for a resident by administering acetaminophen in excess of the manufacturer's recommendations. Despite guidelines to not exceed six tablets in 24 hours, a physician's order allowed for up to 12 tablets, leading to the resident receiving 1,000 mg doses on consecutive days. The DON confirmed the error in dosage administration.
A facility failed to follow procedures for the safe disposition of controlled medications for a resident. The review found no evidence of two licensed nurses being present and signing for the removal and destruction of a Fentanyl patch, nor documentation for the destruction or return of Methadone tablets. The Director of Nursing confirmed the lack of required documentation.
A facility did not act on a pharmacist's recommendation for a resident with heart disease and sleep apnea. The pharmacist identified medication irregularities, but the resident's record lacked a report addressing these issues. The DON confirmed the absence of the report.
Failure to Provide Meal Supervision, Nutritional Assessments, and Ordered Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance and supervision with meals and to follow its own policies for nutritional assessment and interventions. One resident with a history of CVA, right-sided hemiplegia, dysphagia, and documented history of pocketing food was care planned and listed on the Kardex as needing supervision with eating. Despite this, surveyor observations during a lunch meal showed the resident eating without any staff present to supervise or assist. The speech therapist confirmed that the resident required staff supervision during meals due to dysphagia and pocketing of food and that staff should have been present during the observed lunch. The facility also failed to complete required nutritional assessments for multiple residents who experienced significant weight changes. The facility’s policy required baseline weights on admission, routine weight monitoring, and comprehensive nutritional assessments by the RD within 14 days of admission and periodically thereafter, with additional monthly reviews for high-risk residents. However, several residents with diagnoses such as muscle wasting, morbid obesity, diabetes, heart failure, respiratory failure, and muscle weakness had documented weight losses over time without corresponding nutritional assessments. Specifically, residents admitted in 2021, 2024, and 2025 had weight records showing notable decreases, yet their clinical records lacked evidence of comprehensive nutritional assessments after earlier dates, including after admission for one resident. Additionally, the facility did not implement or follow through on nutritional interventions identified in RD assessments. One resident’s nutritional assessment noted a 20-pound decrease in the past month and questioned whether the most recent weight might be an error, recommending a reweigh; the record contained no evidence that a reweigh was completed. Another resident’s nutritional assessment documented an unplanned significant weight loss over 30 days and recommended adding a House Shake at dinner, with notification to Dietary the same day; the facility’s records lacked evidence that the House Shake was added to the resident’s meal plan or orders. During an interview, the Nursing Home Administrator confirmed the absence of required nutritional assessments, the lack of meal supervision for the resident requiring it, and the failure to complete recommended nutritional interventions.
Failure to Timely Notify Physician of Abnormal Lab Result
Penalty
Summary
The facility failed to ensure timely physician notification of an abnormal laboratory result for one resident, as required by its policy on changes in a resident's condition. The facility policy dated 2/02/26 stated that the resident, attending physician, and resident representative would be promptly notified of changes in the resident's medical or mental condition or status. Resident R2 was admitted on 1/22/22 with diagnoses including Alzheimer's disease, atrial flutter, muscle weakness, and high blood pressure. A lab report in the resident's clinical record showed that a specimen collected on 11/26/25, received and reported on 11/27/25, revealed an abnormal potassium level. Progress notes documented that the abnormal potassium findings were not reviewed with the physician until 12/11/25, at which time the resident was transferred to the hospital related to the potassium level obtained on 11/26/25. The record lacked evidence that the physician was notified in a timely manner of the abnormal potassium result, despite the facility's policy requiring prompt notification of changes in condition. During an interview on 3/04/26, the Assistant Director of Nursing confirmed that there was no evidence of timely physician notification and acknowledged the lack of immediate notification regarding the abnormal potassium level from 11/26/25.
Environmental Deficiencies in Ceiling Tiles and Baseboard Registers
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable homelike environment on two of five nursing units (East 1 and the secured unit). During observations conducted with the DON at approximately 1:10 p.m. on 2/8/26, surveyors noted several brown-stained ceiling tiles in the secured unit’s common hallway and in the East 1 resident lounge. Additional observations revealed broken or missing sections of baseboard registers in two resident rooms (rooms 919 and 928). The DON confirmed the presence of the stained ceiling tiles and the damaged or missing baseboard registers at the time of the observations. No specific resident medical histories or conditions were described in relation to these environmental deficiencies.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that required daily nurse staffing information was posted. On 2/7/26 at 11:45 a.m., an observation revealed that the daily staffing posting was not publicly displayed anywhere in the facility. During an interview conducted at the time of this observation, the Director of Nursing confirmed that the required staffing information was not posted. This deficiency was cited under 28 Pa. Code 201.14(a), which addresses the responsibility of the licensee.
Delayed Medication and Enteral Feeding Due to Insufficient Nursing Staff
Penalty
Summary
The facility failed to provide sufficient nursing staff with appropriate skill sets to meet the needs of all residents, as required by facility policy and state regulations. On a specific date, there was only one nurse available for the entire building during the 3:00 p.m. to 11:00 p.m. shift, resulting in significant delays in the administration of medications and enteral feedings. Clinical records showed that one resident's enteral feeding, scheduled for 4:00 p.m., was not started until 9:42 p.m., and their Lispro Insulin, ordered before dinner at 5:00 p.m., was also delayed until 9:42 p.m. Another resident's enteral feeding, also scheduled for 4:00 p.m., was not started until 10:24 p.m., and a third resident's feeding, scheduled for 6:00 p.m., was delayed until 7:46 p.m. Multiple staff interviews confirmed that the delays were directly related to short staffing on the identified date. The only nurse on duty during the affected shift was responsible for all medication cart keys and the care of all residents, which contributed to the significant delays in medication and feeding administration. The Nursing Home Administrator also confirmed that the staffing shortages led to these delays for the affected residents.
Failure to Maintain Required Dishwashing Machine Temperatures and Incomplete Temperature Logging
Penalty
Summary
The facility failed to maintain dishwashing machine water temperatures in accordance with manufacturer recommendations for food service safety. Observations in the kitchen dishroom revealed that the dishwashing machine's rinse cycle temperature was measured at 166-168 degrees F, which is below the required minimum of 180 degrees F as specified by the manufacturer and facility policy. The Dietary Manager confirmed at the time of observation that the rinse cycle temperature did not meet the required standard. Additionally, a review of the dishwasher temperature log for the month of April 2025 showed that the evening shift did not record any dishwasher temperatures for the wash and rinse cycles for the entire month. The Dietary Manager acknowledged that staff are expected to log these temperatures and notify management and maintenance if the required temperatures are not met. These failures were confirmed through staff interviews and review of facility records.
Failure to Follow Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
The facility failed to adhere to established infection prevention and control practices, specifically regarding Enhanced Barrier Precautions (EBP) across all five resident units. Facility policy required the use of gowns and gloves for high-contact care activities involving residents with chronic wounds, indwelling devices, or colonization/infection with multi-drug resistant organisms (MDROs). Observations revealed that staff did not don appropriate personal protective equipment (PPE), such as gowns and gloves, when providing wound care to a resident with a chronic stage three pressure ulcer who was under EBP. The staff member also failed to perform hand hygiene before the procedure and did not change gloves or wash hands after removing a soiled dressing, contrary to facility policy. Interviews with staff confirmed these lapses in following EBP protocols. Additionally, PPE was not readily available at the doorways or hallways for rooms housing residents requiring EBP, including those with chronic wounds, indwelling catheters, tube feedings, and other medical devices. During medication administration, an LPN was observed wearing gloves while preparing medications but touched multiple surfaces and personal items without changing gloves, then handled medications directly with the same gloves. The LPN also picked up dropped medications and placed them into the medication cup without changing gloves. Staff interviews confirmed awareness of the correct procedures but acknowledged the failures to follow them during the observed events.
Failure to Ensure POLST and Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that a resident's Pennsylvania Order for Life Sustaining Treatment (POLST) and physician orders were consistent and accurately reflected the resident's or their representative's wishes regarding life-sustaining treatment. Review of the clinical record for a resident with diagnoses including dementia, anxiety, and gastroesophageal reflux disease showed that the POLST form was incomplete, lacking documentation of the resident's or representative's advance directive wishes. Additionally, the only documented order in the clinical record was for Full Code (CPR), with no evidence that the resident or their representative had been provided written information on advance directives or assisted in formulating such directives. During staff interview, a registered nurse confirmed that the POLST for this resident did not reflect the required information and had not been properly completed or signed by a physician to indicate the resident's current wishes. The nurse also acknowledged that staff rely on the paper chart to determine life-sustaining treatment preferences during emergencies, but in this case, the necessary documentation was missing. This deficiency was cited under multiple Pennsylvania state codes related to management, resident rights, medical records, and resident care policies.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in three resident rooms, as evidenced by multiple observations of black substances on the walls, particularly around window sills, and areas where paint was peeling off. These conditions were confirmed by the Maintenance Director, who acknowledged the presence of the black substance and the peeling paint, and stated that such conditions should not exist in resident rooms. Facility policies reviewed indicated that maintenance and housekeeping are responsible for ensuring the building is kept in good repair, free from hazards, and maintained in a sanitary and comfortable manner. Additionally, a resident reported that their bathroom sink had not drained since admission, requiring them to use another room to wash up. Multiple observations confirmed that the sink was full of water and not draining, with a brown substance running down the wall under the sink and a bubbled appearance on the wall and floor tiles extending to the toilet. The Maintenance Director confirmed these findings and agreed that the sink should drain properly and the wall and floor should not have a bubbling appearance. These deficiencies were found to be in violation of facility policy and state code regarding the responsibility of the licensee to maintain a safe and homelike environment.
Failure to Provide Baseline Care Plan Summaries Upon Admission
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to two residents and/or their representatives within 48 hours of admission, as required by facility policy. Specifically, the clinical records for one resident with diabetes and hypertension, and another resident with diabetes, paraplegia, and hypertension, did not contain evidence that these documents were given to the residents or their representatives. This deficiency was confirmed by a registered nurse who acknowledged the absence of documentation in the clinical records for both residents.
Failure to Develop Care Plan for Hand Splint Use
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing the use of a resting hand splint/palm roll splint for one resident. The resident, who had diagnoses including diabetes, paraplegia, and hypertension, was admitted with orders and therapy recommendations for the use of a hand splint to manage contractures. Despite a therapy discharge summary and physician's order specifying the use of the splint for set periods each day, a review of the resident's care plans showed no evidence that a care plan was created for this intervention. The Therapy Director confirmed during an interview that the care plan for the splint was missing and acknowledged that it should have been developed.
Failure to Apply Physician-Ordered Palm Roll Splint for Contracture Management
Penalty
Summary
A resident with a history of diabetes, paraplegia, and hypertension was admitted to the facility and had documented limited range of motion. The resident was discharged from therapy with instructions to wear a resting hand splint on the left hand for up to 8 hours. Subsequently, a physician's order was issued for the resident to wear a palm roll splint for 4 hours in the morning and 4 hours in the evening for contracture management. However, review of the resident's documentation showed no evidence that the palm roll splint was applied as ordered. Multiple observations over several days revealed that the resident was consistently found without the palm roll splint on the left hand, despite the splint being present in the room or on the bedside stand at times, and at other times not visible in the room. During an interview, the Director of Nursing confirmed that the resident did not have the palm roll splint applied per physician's orders. This failure to provide the ordered treatment and services for contracture management constituted a deficiency in care for the resident with limited range of motion.
Failure to Discard Outdated Medications and Label Opened Drugs
Penalty
Summary
The facility failed to properly manage and discard outdated medications across multiple medication carts and a medication room. Observations revealed that open insulin pens and vials, including Lantus, Lispro, and Humalog, were found without dates indicating when they were opened, making it impossible for staff to determine appropriate discard dates. In one instance, an open Lantus insulin pen was found with an open date that exceeded the manufacturer's recommended 28-day usage period. Additionally, an open vial of Tubersol was found with an open date that was beyond the 30-day discard period specified by the manufacturer. Staff interviews confirmed that the medications in question lacked required open dates or were kept past their recommended usage periods, and staff acknowledged that these medications should have been discarded. The facility's policy requires that the expiration or beyond-use date be checked prior to administration and that the date opened be recorded on multi-dose containers, but these procedures were not followed for the medications observed.
Failure to Maintain Full-Time Director of Nursing Coverage
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) worked full-time, defined as 35 hours per week, in the building. Review of facility deployment sheets showed that the DON was assigned to work as a charge nurse and floor nurse on multiple days, rather than performing the duties of the DON. During an interview, the DON confirmed working in these alternate nursing roles instead of fulfilling the required full-time DON responsibilities, resulting in the DON not meeting the mandated hours for the position. No information about specific residents or their medical conditions was included in the report.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the required daily nurse staffing information was posted in a publicly accessible area. On 4/25/25 at 10:46 a.m., an observation revealed that the daily staffing posting was not displayed as required. This absence of posting was confirmed during an interview with the Director of Nursing at the time of the observation. No information regarding residents or their medical conditions was included in the report.
Failure to Follow Physician's Orders for Lab Tests
Penalty
Summary
The facility failed to adhere to physician's orders for laboratory blood draws for three residents, leading to a deficiency in providing appropriate treatment and care. Resident R1, diagnosed with chronic obstructive pulmonary disease, muscle weakness, and respiratory failure, had a physician's order for a Comprehensive Metabolic Panel (CMP) and a Complete Blood Count (CBC) with differential to be drawn on a specific date. However, the CBC was drawn a day late, and there was no evidence that the CMP was drawn at all. Resident R2, with diagnoses including COPD, respiratory failure, and dementia, had a physician's order for routine potassium level checks on specific days of the month, but there was no evidence that these were conducted in December. Similarly, Resident R3, diagnosed with type 2 diabetes, muscle weakness, and lack of coordination, had orders for a CMP and CBC with differential, which were not collected as ordered. The Director of Nursing confirmed these lapses during an interview, indicating a failure to follow physician's orders for laboratory testing.
Plan Of Correction
Twinbrook Healthcare acknowledges the importance of adhering to physician orders to ensure quality care and has taken immediate corrective actions to address the cited deficiencies. Following identification of the missed laboratory draws for Residents R1, R2, and R3, the attending physicians were promptly notified, and new orders for the required laboratory tests were obtained and completed. A review of the clinical records confirmed that no adverse reactions occurred as a result of the missed labs for the residents cited. To ensure ongoing compliance, the Director of Nursing (DON) or designee conducted a full audit of all current lab orders for facility residents to verify that laboratory tests were completed as ordered. No additional issues were identified during the audit. Moving forward, lab requests will be reviewed by way of electronic medical record generated reports of all physician ordered labs three (3) times a week for four (4) weeks and then monthly for two (2) months by the DON or designee to confirm compliance with physician orders. Any discrepancies will be immediately addressed, and findings will be reviewed in Quality Assurance Performance Improvement (QAPI) meetings. In addition, all nursing staff have been re-educated on the facility's policy for taking and complying with lab draw orders. Education sessions, led by the DON or designee, emphasized the importance of following physician orders for diagnostic testing and maintaining accurate documentation. Education completed by 1/20/2025, and compliance will be reinforced through ongoing training during new staff orientation and regular in-service sessions. These measures have been implemented to ensure adherence to professional standards of practice and the delivery of quality, person-centered care. Full implementation of this Plan of Correction was completed by 1/20/2025.
Deficiency in Laboratory Services and Supplies
Penalty
Summary
The facility failed to ensure an organized system and adequate supplies for timely and accurate laboratory services for four residents. Observations revealed a lack of necessary supplies for in-house blood draws. Resident R1 had a physician's order for a Comprehensive Metabolic Panel (CMP) and a Complete Blood Count (CBC) with differential, but only the CBC was drawn, and the CMP was not completed. Resident R2 had a standing order for potassium level checks, but there was no evidence of these tests being conducted as ordered in December. Resident R3's orders for a CMP and CBC with differential were not fulfilled, and Resident R4's redraw for ACTH and BNP tests was not completed as requested by the laboratory. The Director of Nursing confirmed the deficiencies, attributing them to the absence of an organized laboratory system and insufficient supplies. The facility's laboratory binder contained incomplete order sheets for all four residents, further indicating a lack of proper documentation and follow-through on laboratory orders. These findings highlight the facility's failure to meet the regulatory requirements for providing or obtaining necessary laboratory services to meet the residents' needs.
Plan Of Correction
Twinbrook Healthcare recognizes the importance of timely and accurate laboratory services to meet the needs of our residents. Following identification of the deficiencies cited, immediate corrective actions were taken to address the issues related to lab supply shortages and the organization of laboratory services. The laboratory supply room was promptly restocked to ensure an adequate supply of materials necessary for in-house blood draws. Additionally, nursing staff were re-educated by Director of Nursing (DON)/designee on the process for monitoring and replenishing laboratory supplies, and supply levels will be audited weekly for four [4] weeks and monthly for two [2] months by the Director of Nursing (DON) or designee to ensure availability of necessary items. Regarding the residents cited in the findings, the attending physicians for Residents R1, R2, R3, and R4 were immediately notified of the missed laboratory draws, and the labs were obtained and completed. A thorough audit of all current laboratory orders for facility residents was conducted to ensure compliance, and no further issues were identified. Weekly reviews of lab requests will be conducted via use of electronic medical records generated reports of physician ordered labs three (3) times a week for four [4] weeks, followed by monthly reviews for two [2] months, to confirm that laboratory tests are being ordered, documented, and completed as required. All nursing staff have been re-educated on the facility's policy for taking and complying with lab draw orders. This education, conducted by the DON or designee, emphasized the importance of adhering to physician orders, maintaining accurate documentation, and ensuring timely completion of all laboratory tests. Education completed by 1/20/2025, and compliance will continue to be reinforced through ongoing education during regular staff in-service sessions. Any discrepancies will be immediately addressed, and findings will be reviewed in Quality Assurance Performance Improvement (QAPI) meetings. Finally, it has been verified that no adverse reactions occurred as a result of the missed laboratory draws for the residents cited in this finding. Full implementation of this Plan of Correction will be completed on 1/20/2025.
Facility Fails to Maintain Homelike Environment Due to Maintenance Issue
Penalty
Summary
The facility failed to maintain a homelike environment for one of the nine residents reviewed. Specifically, the baseboard heating system in Resident R5's room was observed to be detaching from the wall, creating a noticeable gap. This observation was made during a survey on December 22, 2024, at approximately 10:30 a.m. The facility's policy, dated November 8, 2024, mandates that housekeeping and maintenance services should ensure a sanitary, orderly, and comfortable environment. During an interview later that day, the Director of Nursing confirmed that the gap was not homelike and acknowledged that it should have been repaired or replaced.
Plan Of Correction
This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law. Twinbrook Healthcare has taken immediate corrective action to address the cited deficiency and ensure the facility provides a safe, clean, comfortable, and homelike environment for all residents. The gap between the baseboard heating system and the wall in Resident R5's room was repaired on 12/22/24. Additionally, a full-house audit was conducted by the Maintenance staff and was completed on the same day to verify that all baseboard heating systems throughout the facility were securely attached to the walls. No other issues were identified during this audit. To prevent recurrence, Twinbrook Healthcare has implemented an inspection process for all baseboard heating systems to check for proper attachment to walls to maintain a homelike environment to be completed weekly for two [2] weeks and monthly for two [2] months. These inspections will be conducted by the Maintenance Director or a designated staff member for a period of two months, with findings reviewed in Quality Assurance Performance Improvement (QAPI) meetings. Any identified issues will be addressed promptly. The Maintenance Director or designee will re-educate all staff on the facility's policy regarding reporting maintenance concerns, including the importance of promptly notifying the Maintenance Department of any issues affecting the safety, cleanliness, or comfort of the environment. Re-education sessions will be completed by 1/20/2025, and ongoing education will be provided during orientation for new hires and as part of regular staff training. Through these actions, Twinbrook Healthcare reaffirms its commitment to maintaining a high standard of living for its residents, ensuring their safety and comfort at all times. Full implementation of this Plan of Correction is completed by January 20, 2025.
Physician Documentation Delays in LTC Facility
Penalty
Summary
The facility failed to ensure that physicians wrote, signed, and dated progress notes at required visits for six residents. The facility's policy mandates that attending physicians provide a progress note reflecting the resident's current status, recent history, medications, and treatments at each visit. These notes should be written or entered at the time of the visit or returned to the facility within 30 days if prepared afterward. However, the review of clinical records revealed that the progress notes for all six residents were not provided within the stipulated timeframe, ranging from 27 to 51 days after the physician's visit. The residents involved had various medical conditions, including dementia, Alzheimer's disease, anorexia, malnutrition, stroke, Type 2 Diabetes, and other complex health issues. For instance, one resident's progress note was delayed by 36 days, while another resident's note was delayed by 51 days. In one case, a resident's clinical record lacked any evidence of a physician's visit progress note 43 days after admission. The Director of Nursing confirmed during an interview that the physician did not provide the progress notes in a timely manner for placement in the residents' medical records.
Inadequate Oxygen Therapy Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, specifically regarding the use of supplemental oxygen. The facility's policy on oxygen administration requires care plans to include specific interventions based on resident assessments and physician orders. However, the clinical records for Residents R19, R51, R54, and R66 lacked evidence of such comprehensive care plans. For instance, Resident R19, with diagnoses including heart disease and obstructive sleep apnea, had a physician's order for supplemental oxygen but no corresponding care plan to guide staff. Similarly, Resident R51, with respiratory failure and other conditions, had care plans that did not adequately address the use of supplemental oxygen. Resident R54, diagnosed with heart disease and COPD, had care plans that were inconsistent with the physician's order for oxygen administration. The care plans did not provide clear guidance on the use of supplemental oxygen. Resident R66, with COPD and other serious conditions, also had a care plan that lacked specific interventions for oxygen use. The Assistant Director of Nursing confirmed that the care plans for these residents were inadequate in guiding staff on providing resident-centered care for oxygen therapy.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to review and revise comprehensive care plans to reflect the current care and services for three residents. Resident R4, who was admitted with diagnoses including obstructive sleep apnea, hypertension, diabetes, and hyperlipidemia, had a physician order for continuous positive airway pressure (CPAP) dated December 5, 2023. However, the care plan for Resident R4 lacked evidence of addressing the CPAP requirement. Similarly, Resident R20, admitted with diabetes, hypertension, and chronic kidney disease, had a care plan to address pain with a target date of April 9, 2024, but there is no indication that the care plan was updated by this date. Resident R58, with diagnoses including chronic obstructive pulmonary disease, hypertension, and anxiety, had a physician order for oxygen at four liters per minute dated January 5, 2024. The care plan for Resident R58, however, only addressed oxygen at two liters per minute with a revision date of March 28, 2024. During an interview, the Director of Nursing confirmed that the care plans for these residents were not reviewed or revised to reflect current care and services, acknowledging that care plans should be updated as required.
Deficiency in Respiratory Care Equipment Maintenance
Penalty
Summary
The facility failed to maintain cleanliness and prevent the potential spread of infection regarding respiratory care equipment for six residents. The facility's policy on oxygen administration required weekly cleaning and changing of oxygen tubing, masks, and concentrator filters, as well as the use of sterile water for humidification. However, observations revealed that the oxygen tubing for several residents was not changed as per the schedule, and the concentrator filters were covered with a white, fluffy substance, indicating they had not been cleaned. Resident R19's oxygen tubing was dated several weeks prior, and the humidifier bottle was nearly empty with the tubing disconnected. Resident R51 and Resident R54 also had outdated oxygen tubing and dirty concentrator filters. Resident R66's equipment was similarly neglected, with the oxygen tubing and concentrator filters not maintained according to the physician's orders. Additionally, Resident R4's CPAP mask was found on the floor without a protective barrier, posing a risk of contamination. The Director of Nursing confirmed the discrepancies in the maintenance of the respiratory equipment for these residents, acknowledging that the equipment should have been cleaned and changed as per the physician's orders. The failure to adhere to the facility's policy and physician's orders resulted in a deficiency in providing safe and appropriate respiratory care for the affected residents.
Failure to Ensure Privacy and Dignity for Residents with Catheters
Penalty
Summary
The facility failed to uphold the residents' rights to privacy and dignity by not covering urinary catheter drainage bags for two residents. The facility's policy on Indwelling Catheter Use and Storage, dated 4/26/24, mandates that catheter bags should be covered to maintain resident dignity and privacy. However, observations on 5/14/24 revealed that the urinary catheter drainage bags of two residents were hanging on their bed frames, visible from the hallway, and lacked privacy covers. Resident R8, who has diagnoses including neuromuscular dysfunction of the bladder, diabetes, and heart failure, was observed with an exposed catheter bag. Similarly, Resident R69, with diagnoses of diabetes, orthostatic hypotension, and venous thrombosis, also had an exposed catheter bag. The Director of Nursing confirmed during an interview that the catheter drainage bags for both residents were not covered, acknowledging that all catheter drainage bags should be covered to ensure resident privacy and dignity.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to a resident and/or their representative within 48 hours of admission. The facility's policy, dated 4/26/24, mandates that a written summary of the baseline care plan should be provided in a language understandable to the resident or representative. This summary must include the resident's initial goals, a summary of medications and dietary instructions, and any services and treatments to be administered by the facility. However, for a resident admitted with chronic respiratory failure, pneumonia, and epileptic seizures, there was no evidence in the clinical record that such a summary was provided. The Director of Nursing confirmed this omission during an interview, acknowledging the lack of documentation in the resident's clinical record.
Inappropriate Pain Management for a Resident
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident, identified as Resident R19, who required such services. The deficiency was identified through a review of the manufacturer's recommendations, facility policy, clinical records, and staff interviews. The manufacturer's guidelines for administering acetaminophen (Tylenol) specified not to exceed six tablets in 24 hours. However, a physician's order dated 4/12/24 instructed staff to administer two acetaminophen 500 mg tablets every four hours as needed for pain, which could result in up to 12 tablets in 24 hours, exceeding the manufacturer's recommendations. Resident R19, who had diagnoses including heart disease, irregular heartbeat, heart failure, and obstructive sleep apnea, was administered acetaminophen 1,000 mg on two separate occasions on consecutive days, further exceeding the recommended dosage. The Director of Nursing confirmed the discrepancy between the physician's order and the manufacturer's recommendations, as well as the incorrect administration of acetaminophen.
Failure in Controlled Medication Disposition Procedures
Penalty
Summary
The facility failed to implement procedures for the accurate and safe disposition of controlled medication records for a resident, identified as CR94, whose closed clinical record was reviewed. According to the facility's policy on the disposal of medications, controlled substances remaining in the nursing care center after discontinuation must be securely stored and destroyed in the presence of two licensed nurses, with documentation maintained as per federal and state regulations. However, the review revealed that there was no evidence of two licensed nurses being present and signing for the removal and destruction of Resident CR94's Fentanyl patch on two occasions. Additionally, there was no documentation of the destruction or return to the pharmacy of the resident's remaining Methadone tablets. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the lack of documentation for the required presence and signatures of two licensed nurses during the medication disposition process for Resident CR94. The absence of proper documentation and adherence to the facility's policy and state regulations regarding the handling of controlled substances was identified as a failure in the facility's pharmaceutical services, specifically concerning the safe and accurate disposition of controlled medications.
Failure to Act on Pharmacist's Recommendation for Medication Irregularities
Penalty
Summary
The facility failed to ensure that a pharmacist's recommendation was reviewed and acted upon for a resident, identified as Resident R19. According to the facility's policy on Medication Regimen Review, staff are required to address all recommendations made by the pharmacist. Resident R19, who was admitted with diagnoses including heart disease, irregular heartbeat, heart failure, and obstructive sleep apnea, had irregularities identified in their medication regimen by a consultant pharmacist on January 27, 2024. However, the clinical record for Resident R19 lacked evidence of a pharmacy recommendation report addressing these irregularities. This was confirmed during an interview with the Director of Nursing, who acknowledged the absence of the report in the resident's clinical record.
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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