Village At Penn State, The
Inspection history, citations, penalties and survey trends for this long-term care facility in State College, Pennsylvania.
- Location
- 260 Lion's Hill Road, State College, Pennsylvania 16803
- CMS Provider Number
- 396092
- Inspections on file
- 16
- Latest survey
- June 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Village At Penn State, The during CMS and state inspections, most recent first.
Surveyors identified multiple sanitation and food storage deficiencies, including soiled kitchen equipment, dirty floors, and undated food items in freezers. Observations included buildup on sheet pans, unclean carts and tables, pooled liquid in the pantry, and improper storage of food and non-food items together. These issues were confirmed with facility leadership.
Two residents received PRN pain medications without clear parameters or guidance for staff on which medication to administer based on pain levels. The facility lacked policies defining pain severity and did not provide specific instructions in physician orders, leading to inconsistent pain management practices.
A resident was found self-administering Flonase and Afrin nasal sprays without a physician's order or documented assessment by the facility to determine her ability to safely self-administer these medications. The medications were kept at her bedside, and the lack of required authorization and evaluation was confirmed by the NHA and DON.
Two residents with a history of falls and cognitive or physical impairments were not provided with required fall prevention interventions or adequate supervision. One resident fell from a wheelchair due to missing dycem, as specified in the care plan, and another fell while ambulating with a nurse aide who was not providing close supervision, despite therapy documentation indicating the need for stand-by or contact guard assistance.
The facility failed to maintain proper food storage and sanitation in the main and smaller kitchens. Observations included undated and expired food items, dust accumulation, and debris around dumpsters. A dishwasher was seen without a beard guard, and an air conditioning unit had a black substance build-up. These issues were discussed with the Nursing Home Administrator and DON.
A resident experienced verbal and physical mistreatment by an RN during an assessment after a fall. Witnesses reported the RN was rough and rude, rolling the resident into a door jamb and threatening to mark her as a refusal. The RN cited stress and personal issues as contributing factors. The facility did not substantiate abuse allegations due to lack of intent and failed to educate staff on stress management and abuse prevention.
A facility failed to monitor the effectiveness or adverse consequences of psychotropic medication for a resident with a physician's order for Zoloft, used to treat depression. The resident's care plan required monitoring for side effects and effectiveness, but there was no documented evidence of such monitoring. This deficiency was confirmed by the DON and Nursing Home Administrator.
Sanitation and Food Storage Deficiencies in Kitchen and Pantry Areas
Penalty
Summary
Surveyors observed multiple sanitation and storage deficiencies in the facility's main kitchen, Atrium kitchen, and pantry. In the Atrium kitchen, several sheet pans in use had significant black buildup, and a plastic wrap holder on the production table was found with dried liquid splatter, food crumbs, and dust both inside and outside. The flooring under the dish machine, cooler, and cooking equipment had visible dirt and debris, and a three-tier cart used to store clean glasses and trays was soiled with dried spills and food debris. In the main kitchen, the walk-in freezer floor had a significant buildup of dirt and debris, and a speed-rack in the walk-in cooler was soiled with dried food, spills, dust, and debris. The wall behind the handwashing sink was covered in brown splatter, and cooking equipment such as the tilt kettle, braising kettle, flat top, grill, and stove had thick dust and blackened debris buildup. The director of dining services indicated that some equipment was out of service and awaiting replacement. In the pantry storage area, surveyors found a large amount of pooled liquid in front of the ice machine, sticky and debris-laden flooring, and dirt under equipment and along wall edges. A metal table holding a juice dispenser had dried orange spills and a sticky, dusty lower shelf, with a cardboard box and an opened can of paint stored on it. Two upright freezers contained multiple food items, including cupcakes, potato tots, onion rings, cream chipped beef, beef stew, and meat lasagna, none of which were labeled with dates to indicate when they were placed in storage or when they should be used by. These findings were reviewed with facility leadership.
Lack of Pain Management Parameters for PRN Medications
Penalty
Summary
The facility failed to provide pain management services consistent with professional standards of practice for two residents. For one resident, physician orders included as-needed (PRN) medications for pain, such as Acetaminophen and Oxycodone, but the orders did not specify pain level parameters for when each medication should be administered. The resident's medication administration records showed that Oxycodone was given for varying pain levels, including moderate and severe pain, but Acetaminophen was not administered at all during the month. The facility did not have a policy defining mild, moderate, or severe pain, and there was no guidance for nurses on which medication to use based on the resident's reported pain level. For another resident, orders for PRN Acetaminophen and Tramadol were present, but again, there were no pain scale parameters to guide staff on which medication to administer for specific pain levels. The medication administration records indicated that both medications were given for a range of pain scores, including high pain levels, but without documented criteria for their use. Interviews with the DON and Nursing Home Administrator confirmed the absence of pain management parameters and policies, resulting in inconsistent and potentially inappropriate pain management for both residents.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
A deficiency was identified when a resident was observed self-administering Flonase and Afrin nasal sprays, which she had brought from the hospital and kept on her bedside table or windowsill since admission. The resident confirmed that she self-administered these medications. Review of the clinical record revealed there was no physician's order permitting self-administration, nor any documentation that the facility had assessed or determined the resident's ability to safely self-administer her medications. This information was confirmed with the Nursing Home Administrator and Director of Nursing.
Failure to Implement Fall Prevention Interventions and Provide Adequate Supervision
Penalty
Summary
The facility failed to implement care-planned interventions and provide adequate supervision to prevent accidents for two residents with a history of falls. One resident, who had severe cognitive impairment and was assessed as a fall risk due to unsteady gait and poor balance, had a care plan intervention requiring dycem on the wheelchair seat and pressure alarm to prevent sliding. However, on the night of the incident, the dycem was not in place, and the resident fell from the wheelchair, sustaining a skin tear. Staff documentation confirmed the absence of the dycem at the time of the fall, and facility leadership could not provide further documentation regarding the missing intervention. Another resident, also identified as a high fall risk with a recent history of multiple falls, intermittent confusion, and decreased balance, experienced a fall while ambulating in the hallway with a nurse aide. The resident lost consciousness briefly after hitting her head during the fall and was transported to the hospital. Clinical records and therapy notes indicated that the resident required supervision or contact guard assistance for ambulation and needed frequent verbal cues for safety. Despite these documented needs, the resident's care plan did not specify the required level of ambulation assistance, and the nurse aide was walking ahead of the resident rather than providing close supervision at the time of the fall. The facility's failure to follow care-planned interventions for fall prevention and to provide adequate supervision for residents at high risk for falls resulted in preventable accidents. Documentation and interviews confirmed that the necessary interventions and supervision were not consistently implemented for these residents, directly contributing to their falls and injuries.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food storage and a sanitary environment in both the main kitchen and a smaller kitchen area on the skilled nursing unit. During an initial tour, it was observed that the walk-in freezer contained undated and open packages of veggie burgers and ground pork sausage, as well as an undated bag of breadsticks. The walk-in cooler had expired onions, undated celery, expired halibut, unlabeled potatoes, and expired avocado halves. Additionally, the cooler's condenser unit had a significant accumulation of dust. The area around the main kitchen dumpsters was littered with medical gloves, Styrofoam cups, dead leaves, and other debris. Inside the main kitchen, a partially filled milk container and a lemon juice container were found with expired dates, and there was a significant accumulation of dust on a ceiling vent and adjacent ceiling tile. The protective coverings on two ceiling lights were partially ajar, and there was a damaged wall corner between the kitchen and dishwashing area, which allowed water to leak and puddle on the floor. In the smaller kitchen on the skilled nursing unit, a floor drain near the food prep area contained various debris. Employee 5, a dishwasher, was observed in the kitchen area with a full beard but without a beard guard, which the facility does not require. An air conditioning unit in the same area had an extensive build-up of a black colored substance on its vents. These observations were reviewed with the Nursing Home Administrator and Director of Nursing, indicating a failure to adhere to professional standards for food storage and sanitation.
Failure to Prevent Abuse and Educate Staff on Stress Management
Penalty
Summary
The facility failed to prevent abuse for a resident, identified as Resident 8, who was involved in an incident on May 9, 2024. A nurse aide found the resident on the floor, having slid out of bed, and called for a registered nurse, Employee 2, to assess her for injuries. During the assessment, Employee 2 was reported to have been verbally inappropriate and physically rough with Resident 8. Witnesses, including a nurse aide and a licensed practical nurse, reported that Employee 2 rolled Resident 8 into a door jamb, causing her pain, and spoke to her in a rude manner, threatening to mark her as a refusal if she did not comply. Employee 2 admitted to being stressed and frustrated due to personal circumstances and work demands, which she believed contributed to her behavior. The facility's investigation into the incident revealed that Resident 8 did not sustain any injuries from the fall or the subsequent handling by Employee 2. However, the Director of Nursing's summary indicated that Resident 8 felt mistreated and reported being yelled at and thrown against the wall by Employee 2. Despite these findings, the facility did not substantiate the abuse allegations, citing a lack of intent to harm by Employee 2. Furthermore, the facility failed to educate staff on stress management and abuse prevention following the incident, as Employee 2 did not return to the facility, and no further staff education was conducted to prevent recurrence.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to monitor the effectiveness or adverse consequences of psychotropic medication use for one of the residents reviewed. Resident 8 had a physician's order for Zoloft, a medication used to treat depression, at a dosage of 25 milligrams once daily. The resident's care plan included a focus area for depression related to dementia, with a goal for the resident to remain free of signs and symptoms of depression, anxiety, or sad mood. The care plan interventions required monitoring for side effects and effectiveness of the medication. However, there was no documented evidence that Resident 8 was being monitored for side effects or effectiveness of the Zoloft medication. This was confirmed during an interview with the Director of Nursing and the Nursing Home Administrator. The facility's failure to ensure proper monitoring of the psychotropic medication use for Resident 8 was noted as a deficiency.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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