Uniontown Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Uniontown, Pennsylvania.
- Location
- 129 Franklin Avenue, Uniontown, Pennsylvania 15401
- CMS Provider Number
- 395674
- Inspections on file
- 23
- Latest survey
- July 24, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Uniontown Nursing And Rehab during CMS and state inspections, most recent first.
The facility did not ensure that staff providing services under contractual arrangements completed all required annual trainings, as evidenced by incomplete training records and confirmation from the Nursing Home Administrator.
Five nurse aides did not receive the required 12 hours of annual in-service education, instead receiving only one to four hours each during their respective annual periods. This deficiency was confirmed through review of facility policy, staff education records, and staff interviews.
The facility did not provide required infection control training to seven staff members, including nurse aides, a registered nurse, an occupational therapist, a housekeeping employee, and a dietary employee, as confirmed by review of training records and staff interviews.
The facility did not provide required in-service education on effective communication to several staff members, including a nurse aide, an occupational therapist, a registered nurse, a housekeeping employee, and a dietary employee, as confirmed by review of training records and staff interviews.
The facility did not provide required resident rights training to five staff members, including a nurse aide, an occupational therapist, a registered nurse, and a housekeeping employee, as confirmed by review of training records and interviews with the NHA and DON.
The facility did not provide required annual in-service education on abuse and neglect prevention to two staff members, including an occupational therapist and a housekeeping employee, as confirmed by review of training records and staff interviews. This failure was not in accordance with facility policy and state regulations regarding staff development.
Nine out of ten staff members, including nurse aides, therapy, nursing, laundry, housekeeping, and dietary staff, did not receive mandatory annual training on the facility's QAPI program as required by policy and state regulations. This deficiency was confirmed through review of training records and staff interviews.
The facility did not provide required Compliance and Ethics training to seven staff members, including nurse aides, a registered nurse, an occupational therapist, a housekeeping employee, and a dietary employee, as evidenced by missing documentation of annual in-service education. This was confirmed by the administrator during staff interviews and review of training records.
The facility did not provide required Behavioral Health training to five staff members, including a nurse aide, an occupational therapist, a registered nurse, a housekeeping employee, and a dietary employee, as evidenced by missing documentation in their in-service training records. This deficiency was confirmed by the Nursing Home Administrator and cited under state regulations for staff development and management.
The facility did not comply with its policy on employee hygiene, as a dietary aide was observed in the kitchen without a hair restraint, risking cross-contamination. The Nursing Home Administrator confirmed that kitchen staff should wear hair restraints to prevent foodborne illness.
A resident with vascular dementia and other health issues eloped from the facility due to a failure in the Wanderguard system, which was supposed to alert staff of her departure. Despite regular checks, the device was not functioning, leading to the resident being found outside by an RN. Staff interviews revealed confusion about the maintenance process, and the NHA confirmed the system's failure.
Failure to Ensure Completion of Required Staff Training
Penalty
Summary
The facility failed to implement and maintain an effective training program for individuals providing services under contractual arrangements, as required by their roles. Review of the facility assessment and personnel files revealed that all employees were required to complete both general orientation and annual trainings on topics such as resident rights, abuse prevention, compliance, infection control, dementia care, emergency preparedness, and more. However, a review of ten training records showed that staff providing services had incomplete annual trainings. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the failure to ensure completion of required trainings for these individuals.
Failure to Provide Required Annual In-Service Education to Nurse Aides
Penalty
Summary
The facility failed to provide at least 12 hours of annual in-service education to nurse aides within 12 months of their hire date anniversary, as required by policy and regulation. A review of staff education records and facility policy revealed that five nurse aides received significantly fewer hours of in-service training than mandated, with individual totals ranging from one to four hours during their respective annual periods. The deficiency was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the required training had not been completed for these staff members. This finding was based on a review of facility policy, staff education records, and staff interviews, and it specifically involved five nurse aides who did not meet the annual in-service education requirement.
Failure to Provide Required Infection Control Training to Staff
Penalty
Summary
The facility failed to provide mandatory infection control training to seven out of ten reviewed staff members, as required by its own policy and state regulations. The policy, last reviewed on 10/29/24, mandates that all new and existing staff receive training on infection prevention and control, including written standards, policies, and procedures. Documentation revealed that several staff members, including nurse aides, an occupational therapist, a registered nurse, a housekeeping employee, and a dietary employee, did not have evidence of receiving infection control in-service education within the required timeframes based on their hire dates. During an interview, the Nursing Home Administrator confirmed the lack of infection control training for these staff members. The deficiency was identified through a review of facility policies, training records, and staff interviews, and it was cited under multiple Pennsylvania state codes related to staff development and management responsibilities. No information about residents' medical history or conditions was included in the report.
Failure to Provide Effective Communication Training to Staff
Penalty
Summary
The facility failed to provide required training on effective communication to five out of ten reviewed staff members, as evidenced by a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy mandates that all new and existing staff receive training on effective communication, among other topics, as part of its training program. However, documentation showed that a nurse aide, an occupational therapist, a registered nurse, a housekeeping employee, and a dietary employee did not have records of completing effective communication in-service education within the required timeframes based on their hire dates. During an interview, the Nursing Home Administrator confirmed the lack of effective communication training for these staff members. The deficiency was cited under state regulations regarding the responsibility of the licensee, management, and staff development. No information was provided regarding any residents directly affected or any immediate consequences resulting from this deficiency.
Failure to Provide Resident Rights Training to Staff
Penalty
Summary
The facility failed to provide required training on resident rights to five out of ten reviewed staff members, as evidenced by a review of facility assessment, documents, in-service training records, and staff interviews. The facility's policy mandates an effective training program for all new and existing staff, including education on resident rights and facility responsibilities. However, documentation showed that a nurse aide, an occupational therapist, a registered nurse, and a housekeeping employee did not receive in-service education on resident rights within the required timeframes. The absence of this training was confirmed by the Nursing Home Administrator and the Director of Nursing during an interview. The deficiency was identified through a review of training records, which revealed gaps in compliance with the facility's own training requirements. The affected staff members had varying hire dates, but all lacked documented resident rights training for the most recent annual period. This failure to provide mandated education was found to be in violation of state regulations regarding the responsibility of the licensee to ensure staff are properly trained.
Failure to Provide Required Abuse and Neglect Prevention Training to Staff
Penalty
Summary
The facility failed to provide required training on abuse and neglect prevention for two of ten staff members reviewed. Specifically, an occupational therapist and a housekeeping employee did not have documented in-service education on abuse and neglect prevention within the required annual period following their respective hire dates. Review of facility policy indicated that all new and existing staff must receive training on topics including abuse, neglect, and exploitation prevention, but training records did not show completion for these two employees during the specified timeframes. During staff interviews, the Nursing Home Administrator confirmed that the facility did not provide abuse and neglect prevention training for six of nine staff members reviewed. The deficiency was identified through review of facility policy, personnel in-service training records, and staff interviews. The lack of documented training was found to be out of compliance with state regulations regarding staff development and management responsibilities.
Failure to Provide Required QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) program to nine out of ten reviewed staff members. Review of the facility's policy indicated that all new and existing staff are required to receive training on several topics, including the elements and goals of the QAPI program. Examination of training records and personnel files revealed that staff members from various departments, including nurse aides, an occupational therapist, a registered nurse, laundry, housekeeping, and dietary, did not have documented QAPI in-service education within the required annual period. This lack of documentation was confirmed through review of training records and staff interviews. The deficiency was further substantiated during an interview with the Nursing Home Administrator, who acknowledged that the required QAPI training had not been provided to the majority of staff reviewed. The absence of this training was found to be in violation of the facility's own policy and state regulations regarding staff development and management responsibilities. No information was provided regarding any residents directly affected or their medical conditions at the time of the deficiency.
Failure to Provide Compliance and Ethics Training to Staff
Penalty
Summary
The facility failed to provide required training on Compliance and Ethics to seven out of ten reviewed staff members, as determined through a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy mandates an effective training program for all new and existing staff, including content on compliance and ethics, among other topics. Documentation revealed that several staff members, including nurse aides, an occupational therapist, a registered nurse, a housekeeping employee, and a dietary employee, did not have records of completing the required Compliance and Ethics in-service education within the specified annual timeframes. The deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the lack of documented training for the identified staff members. The absence of this training was found despite the facility's policy and the availability of annual education sessions, indicating a lapse in adherence to established staff development requirements.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide required Behavioral Health training to five out of ten reviewed staff members, as evidenced by a review of in-service training records and staff interviews. The facility's policy mandates that all new and existing staff receive training on several topics, including Behavioral Health, as part of an effective training program. However, documentation showed that a nurse aide, an occupational therapist, a registered nurse, a housekeeping employee, and a dietary employee did not have evidence of completing Behavioral Health in-service education within the required annual period following their respective hire dates. During an interview, the Nursing Home Administrator confirmed the lack of Behavioral Health training for these five staff members. The deficiency was cited under state regulations related to the responsibility of the licensee, management, and staff development. No information was provided regarding the involvement or condition of residents, and the deficiency was based solely on staff training records and facility policy requirements.
Failure to Enforce Hair Restraints in Kitchen
Penalty
Summary
The facility failed to adhere to its policy on preventing foodborne illness through proper employee hygiene and sanitary practices. During an observation, a dietary aide was seen working in the kitchen without a hair restraint, which is a violation of the facility's policy that requires hair nets or caps and/or beard restraints to be worn to prevent hair from contacting exposed food, clean equipment, utensils, and linens. This observation was confirmed by the Nursing Home Administrator during an interview, acknowledging that kitchen staff should wear hair restraints as per the policy. The deficiency was identified during a survey, where it was noted that the facility's failure to enforce the use of hair restraints in the kitchen could potentially lead to cross-contamination, thus compromising food safety standards. The facility's policy, last reviewed on September 13, 2023, clearly outlines the necessity of hair restraints to maintain hygiene and prevent foodborne illnesses.
Elopement Incident Due to Wanderguard System Failure
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for Resident R76, resulting in an elopement incident. Resident R76, who has vascular dementia, diabetes, and high blood pressure, was identified as being at risk for elopement through evaluations conducted on admission, quarterly, and annually. Despite these assessments, Resident R76 was found outside the facility by a registered nurse, indicating a failure in the Wanderguard system, which is supposed to alert staff when a resident at risk for elopement leaves a safe area. Interviews with staff revealed that the Wanderguard system was not functioning correctly for Resident R76, as her device was not working at the time of the incident. Staff members confirmed that the Wanderguard devices are checked every shift for placement and a blinking light, and maintenance conducts weekly checks. However, there was a lack of clarity among staff about the maintenance process, and it was confirmed by the Nursing Home Administrator that the facility did not ensure the Wanderguard system was working properly for Resident R76.
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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