Wecare At Mt Lebanon Rehabilitation And Nrsg Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 350 Old Gilkeson Road, Pittsburgh, Pennsylvania 15228
- CMS Provider Number
- 395434
- Inspections on file
- 56
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Wecare At Mt Lebanon Rehabilitation And Nrsg Ctr during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and physical debility, requiring assistance of two staff for transfers, was transferred by a single nurse aide who relied on incorrect information from a census sheet rather than the care plan. This failure to follow the resident's plan of care resulted in an ankle fracture, with the incident substantiated as neglect after facility investigation.
A review of staffing records and staff interviews revealed that the facility did not provide the minimum required number of nurse aides on several day, evening, and night shifts, resulting in staffing levels below regulatory requirements for the census on those days. The Nursing Home Administrator confirmed the deficiency.
A resident with diabetes, obesity, and hypertension reported that an LPN performed a blood glucose finger stick while she was sleeping on two occasions. The DON and administrator confirmed that the facility did not conduct a full investigation into the alleged abuse, failing to interview the accused employee, witnesses, or other staff, as required by policy.
A medication cart on the first floor was observed left unlocked and unattended in the hallway near the nurse's station, contrary to facility policy requiring all medications and biologicals to be securely stored. Both a nurse and the DON confirmed the cart should have been secured when not in use.
Multiple residents did not receive their selected menu items, including desserts, beverages, supplements, and preferred salad dressings, as documented on their meal tickets. Additionally, artificial sweetener was unavailable for residents with diabetes or those preferring non-sugar options, and staff confirmed the facility could not meet these dietary needs due to supply shortages.
The facility did not consistently offer evening snacks to residents as required by its policy, with several residents reporting that snacks were rarely or never provided and sometimes consumed by staff instead. This failure was confirmed by the administrator and affected the majority of residents interviewed.
Multiple residents reported seeing ants and spiders in their rooms, and observations confirmed the presence of ants in several rooms and common areas. During PTAC unit replacement, no measures were taken to prevent insect entry, and the facility's pest control program was not effectively implemented, as confirmed by the administrator.
The facility failed to provide the required number of nurse aides (NAs) per resident on several shifts. Specifically, the facility did not meet the mandated staffing levels for NAs during the daylight, evening, and night shifts on multiple days. This deficiency was confirmed through staffing documents and an interview with the Nursing Home Administrator.
The facility did not meet the required minimum of 3.20 PPD hours of direct resident care on four days, with PPD hours recorded as 2.73, 2.78, 3.01, and 3.00. This was confirmed by the Nursing Home Administrator after reviewing staffing documents and schedules.
The facility did not meet the required staffing levels for nurse aides on multiple occasions. Specifically, the facility failed to provide the mandated number of NAs during the daylight, evening, and night shifts on various days, as confirmed by the Nursing Home Administrator.
The facility did not meet the required 3.2 PPD hours of direct care on two days, providing only 3.16 and 2.94 PPD hours. This was confirmed by the Nursing Home Administrator.
A resident with severe cognitive impairment eloped from the facility due to inadequate supervision and outdated care plans. The resident was found on a highway by a CNA and returned to the facility. The incident highlighted lapses in updating elopement risk assessments and care plans.
A facility failed to reassess a resident with cognitive decline for elopement risk, despite a significant drop in BIMS scores and incidents of confusion and anxiety. The resident, diagnosed with dementia, was found outside the facility on a highway, indicating a risk of elopement. The facility did not update the resident's care plan or complete a new elopement risk assessment, as confirmed by interviews with the DON and Regional DON.
The facility failed to maintain a homelike environment due to lukewarm water issues and structural problems on two floors. Residents and staff reported that water needed to run for extended periods to become warm, and there were holes in walls and unfinished plaster. A black substance with a musty odor was found on a shower room ceiling. The Maintenance Director confirmed the water system's limitations, affecting the entire building.
A facility failed to maintain infection control practices during a dressing change, as observed by surveyors. The RN did not wash or sanitize hands before donning clean gloves multiple times, did not use a clean barrier for items on the bedside table, and failed to label the dressing with date, time, and initials. Despite a bathroom being available, the RN claimed there was nowhere to wash hands. The Director of Nursing confirmed the failure to prevent cross-contamination.
The facility did not provide behavioral health training for ten staff members, including nurse aides, an activities aide, a dietary aide, a housekeeping employee, an RN, and an occupational therapy employee. This deficiency was confirmed by the Nursing Home Administrator and violates Pennsylvania Code regulations on licensee responsibility, management, and staff development.
The facility failed to provide several residents with the opportunity to formulate an advance directive, as required by policy. Clinical records for residents with various medical conditions lacked documentation of advance directives or evidence that residents were given the chance to create one. This was confirmed by a social worker during an interview.
The facility failed to provide the required 12 hours of annual in-service education for five nurse aides, who each received only 4 hours of training within the specified timeframe. This deficiency was confirmed by the Nursing Home Administrator, acknowledging the shortfall in meeting the mandated training requirements.
A facility failed to conduct a required Level II PASARR evaluation for a resident diagnosed with Schizophrenia and bipolar disorder. Despite the facility's policy requiring a Level I screening and referral for Level II evaluation, the necessary referral and evaluation were not completed, as confirmed by a review of clinical records and an interview with a social services employee.
The facility failed to notify physicians and assess two residents for abnormal blood glucose levels. One resident had CBG levels of 53 and 477, while another had levels of 62 and 416, without proper notification or assessment. Care plan interventions were not followed, and interviews with LPNs revealed inconsistencies in handling abnormal CBG levels.
A resident with multiple health conditions required extensive assistance for bed mobility, but the facility failed to document this need adequately. The resident rolled out of bed during care, resulting in a head injury. The incident was witnessed, and the resident was taken to the hospital for evaluation. The Director of Nursing confirmed the lack of proper documentation contributed to the fall.
The facility failed to dispose of expired medical supplies in a medication room on the first floor. Observations revealed expired povidone iodine swabsticks, oil emulsion dressings, super absorbent dressings, strip paste coloplasts, and a small bore extension set. The Nursing Home Administrator confirmed the oversight, violating resident care policies and nursing services regulations.
The facility did not complete annual performance evaluations for five nurse aides, violating personnel policies. Employees hired between 1993 and 2020 lacked documented evaluations, confirmed by the Nursing Home Administrator. This deficiency breaches staff development regulations.
The facility failed to implement and maintain an effective training program for staff under contractual agreements, as required by their policy. The Director of Nursing and the Nursing Home Administrator confirmed that the previous HR Director did not maintain accurate and complete training files, leading to a deficiency in the facility's adherence to its training policy.
The facility failed to provide communication training to ten direct care staff members, including nurse aides, an activities aide, a dietary aide, a housekeeping employee, a registered nurse, and an occupational therapy employee. This deficiency was confirmed by the Nursing Home Administrator and violates the facility's responsibility under relevant state codes.
The facility did not provide training on resident rights to ten staff members, including nurse aides, an activities aide, a dietary aide, a housekeeper, a registered nurse, and an occupational therapy employee. This deficiency was confirmed by the Nursing Home Administrator and violates Pennsylvania Code sections on licensee responsibility and staff development.
The facility did not provide mandatory QAPI training to ten staff members, including nurse aides, an activities aide, a dietary aide, a housekeeping employee, a registered nurse, and an occupational therapy employee. This was confirmed by the Nursing Home Administrator and constitutes a violation of state regulations regarding staff development and licensee responsibility.
The facility did not provide compliance and ethics training for ten staff members, including nurse aides, an activities aide, a dietary aide, a housekeeping employee, a registered nurse, and an occupational therapy employee. This was confirmed by the Nursing Home Administrator.
A resident with anxiety and depression, who used jewelry making as a therapeutic activity, did not have her personal belongings returned for four weeks after returning from a psychiatric commitment. The facility delayed the return of her possessions to ensure she would remain in her new room, which was confirmed by the Social Worker and acknowledged by the Nursing Home Administrator.
Failure to Provide Adequate Supervision During Resident Transfer Resulting in Injury
Penalty
Summary
The facility failed to provide adequate supervision during transfers for one resident, resulting in an ankle fracture. The resident in question had a history of diabetes, arthritis, and physical debility, and was assessed as severely cognitively impaired with a BIMS score of 0. According to the resident's care plan and Kardex, the resident required assistance from two staff members for transfers. However, on the day of the incident, the resident was transferred by a single nurse aide, contrary to the documented care plan. The nurse aide relied on an outdated census sheet that incorrectly listed the transfer status and did not consult the electronic charting system for the most current information. Following the transfer, the resident was found to have swelling, warmth, and tenderness in the left foot and ankle, which was later confirmed by x-ray to be a fracture. The resident was unable to communicate what had occurred due to cognitive impairment. The facility's investigation substantiated neglect, as the nurse aide did not follow the resident's plan of care, leading to actual harm. Staff interviews and documentation confirmed that the plan of care was not followed during the transfer, resulting in the injury.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet required nurse aide (NA) staffing ratios on multiple shifts over a six-day period, as evidenced by a review of staffing documents and staff interviews. Specifically, the facility did not provide at least one NA per 10 residents during the day shift on two days, one NA per 11 residents during the evening shift on three days, and one NA per 15 residents during the night shift on two days. Staffing records showed that the actual NA hours provided were below the required hours for the census on these dates. The Nursing Home Administrator confirmed during an interview that the facility did not meet the required NA staffing levels on the identified shifts.
Plan Of Correction
The Facility submits this Plan of Correction under the procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the department alleges is deficient under state and/or Federal Long Term Care regulations. This Plan of Correction should not be construed as either a waiver or the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. The CNA schedule is created to ensure staffing ratios reflect the current census per shift. Each shift's staffing is adjusted based on census. When additional staff is needed to meet ratios, shifts are posted on our staffing portal, bonuses are offered, phone calls and text messages are sent to staff. The facility is utilizing agency to assist with open shifts. The facility attendance policy is followed for staff and disciplines occur per policy. Attendance is tracked on a calendar and reviewed weekly. The facility holds a monthly retention committee meeting and ads are posted on Indeed for open positions. Interviews are conducted immediately. We have a dedicated recruiter to assisting us with recruiting and hiring new nursing staff. The Administrator or designee will educate the Nursing Admin, the scheduler, and RN Supervisors on the staffing ratio grid and how to adjust. A staffing meeting will occur daily to review ratios with the NHA, DON, and scheduler. Daily recruiting calls occur to update the status of new applicants and interviews. The 3-week DOH Staffing Calculator Tool will be updated daily to monitor hours. The audits will be taken to QAPI for review.
Failure to Investigate Alleged Abuse and Neglect
Penalty
Summary
The facility failed to investigate incidents of possible abuse and neglect involving one resident. According to facility policy, staff are required to assess, document, and investigate all alleged abuse and neglect, including interviewing witnesses and other relevant individuals. In this case, a resident reported that a nurse entered her room and performed a blood glucose finger stick while she was sleeping on two occasions. The Director of Nursing confirmed that the incident occurred, but the facility did not conduct a full investigation as required by policy. Specifically, the facility did not interview the accused employee, any possible witnesses, other staff members present, or other residents who may have received care from the same employee. The resident involved had diagnoses including diabetes, obesity, and high blood pressure, and was re-admitted to the facility prior to the incident. The failure to follow investigative procedures was confirmed by both the Director of Nursing and the Nursing Home Administrator.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to properly secure a medication cart, as observed during a survey. On the first floor, Team #1's medication cart was found unlocked and unattended in the hallway near the nurse's station. Facility policy requires that medications and biologicals be stored safely and securely in locked compartments, with access limited to authorized personnel. During interviews, both a registered nurse and the Director of Nursing confirmed that the cart was left unattended and unlocked, which was not in accordance with facility policy.
Failure to Provide Resident-Selected Menu Items and Dietary Preferences
Penalty
Summary
The facility failed to provide resident-selected menu items for 14 out of 20 residents, as evidenced by meal observations and review of meal tickets. Specific deficiencies included residents not receiving requested items such as ginger ale, puddings, cookies, ice cream, house supplements, cranberry juice, nutritional supplements, and preferred salad dressings. In one instance, a resident received Italian dressing instead of the requested ranch, which the resident stated caused heartburn. Additionally, several residents consistently received fewer cookies than requested on their meal tickets. During staff interviews and cart inspections, it was revealed that the facility did not have any artificial sweetener available for residents with diabetes or those who preferred non-sugar sweeteners. The Dietary Manager confirmed the absence of artificial sweetener and indicated that the next food delivery was not expected for several days. The Nursing Home Administrator also confirmed the failure to provide selected food items to the affected residents. These findings are in violation of the facility's policy and state dietary service regulations.
Failure to Consistently Provide Evening Snacks to Residents
Penalty
Summary
The facility failed to consistently provide evening snacks to residents as required by its own policy and in accordance with residents' needs and preferences. The facility's policy, dated 9/9/24, states that evening snacks will be routinely offered to all residents. However, interviews with six out of eight residents revealed that snacks were either not provided, only occasionally provided, or not available when requested. Several residents reported that they rarely or never received evening snacks, with some stating that staff consumed the snacks instead of offering them to residents. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged that the facility did not consistently provide snacks as desired by the majority of residents interviewed. The findings indicate a failure to adhere to established policy and to meet the nutritional and personal preferences of residents regarding snack availability outside of scheduled meal times.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program on the Ground Floor nursing unit, as required by its own pest control policy. Multiple residents reported seeing ants and spiders in their rooms, with one resident specifically noting that her room was not treated during a recent exterminator visit. Observations confirmed the presence of ants in several resident rooms, including under and inside PTAC units, as well as in the lounge area where both live ants and dead bugs were found. An empty room with a removed PTAC unit had visible ants in the remaining metal case, which had grates allowing air flow and potential pest entry. Interviews with the Maintenance Director revealed that no measures had been taken to prevent insects from entering the building during PTAC unit replacement. The Nursing Home Administrator confirmed the failure to maintain an effective pest control program for the affected nursing unit. These findings were based on direct observations and resident and staff interviews, and were cited under 28 Pa. Code: 207.2 (a) regarding the administrator's responsibility.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on multiple occasions. Specifically, the facility did not provide the mandated one NA per 10 residents during the daylight shift on five out of eight days, one NA per 11 residents during the evening shift on four out of eight days, and one NA per 15 residents during the night shift on one out of eight days. This deficiency was confirmed through a review of staffing documents and an interview with the Nursing Home Administrator, who acknowledged the failure to meet the staffing requirements on the specified shifts.
Plan Of Correction
The Facility submits this Plan of Correction under the procedures established by the Department of Health in order to comply with the Departments directive to change conditions which the department alleges is deficient under state and/or Federal Long Term Care regulations. This Plan of Correction should not be construed as either a waiver or the facility right to appeal or challenge the accuracy of severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. The CNA schedule is created to ensure staffing ratios reflect the current census per shift. Each shifts staffing is adjusted based on census. When additional staff is needed to meet ratios, shifts are posted on our staffing portal, bonuses are offered, text messages are sent to staff. The Administrator or designee will educate the Nursing Admin, the scheduler and RN Supervisors on the staffing ratio grid and how to adjust. A staffing meeting will occur daily to review ratios and audited for 3 weeks. The Audits will be taken to QAPI for review.
Failure to Meet Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the state-required minimum of 3.20 hours of direct resident care per patient daily (PPD) on four specific days. A review of staffing documents and nursing staff schedules from January 21, 2025, through January 28, 2025, revealed that the facility did not provide the required PPD on January 24, 26, 27, and 28, 2025. Specifically, the PPD hours were 2.73, 2.78, 3.01, and 3.00, respectively, on these dates. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 29, 2025, who acknowledged the failure to meet the required staffing levels on the specified days.
Plan Of Correction
The Nursing schedule is created to ensure staffing ratios reflect the current census per shift to meet PPD. When additional staff is needed to meet PPD, shifts are posted on our staffing portal, bonuses are offered, and text messages are sent to staff. The Administrator or designee will educate Nursing Admin, the Scheduler, and RN Supervisors on the staffing ratio grid and how to adjust. A staffing meeting will occur daily to review PPD and audited for 3 weeks. The Audits will be taken to QAPI for review.
Staffing Deficiencies in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on several occasions between December 10, 2024, and December 15, 2024. Specifically, on December 13, 2024, the facility did not provide the mandated one NA per 10 residents during the daylight shift. Additionally, on December 12 and December 15, 2024, the evening shift was understaffed, with the facility failing to provide one NA per 11 residents. Furthermore, on the night shift of December 15, 2024, the facility did not meet the requirement of one NA per 15 residents. These deficiencies were confirmed by the Nursing Home Administrator during an interview on December 16, 2024.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. P5520 1. The facility cannot correct that the nurse aide staffing ratio was not met on 12/12/24, 12/13/24, and 12/15/24. There were no adverse effects to residents on the identified dates. 2. The scheduler will be re-educated regarding the state ratios by the Nursing Home Administrator/designee. 3. Nursing Administration will be re-educated on staffing ratios by the Nursing Home Administrator/designee. Twice a day staffing meetings will be held to review the schedule with ratios. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios, the scheduler/or designee will call off duty facility staff and will utilize external staffing support resources. The facility has started regular job fairs to increase staffing. 4. Nursing Home Administrator/designee will audit staffing daily for three weeks and monthly for three months to ensure staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Failure to Meet Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the state-mandated requirement of providing a minimum of 3.2 hours of direct resident care per patient daily (PPD) on two specific days. A review of staffing documents and nursing schedules from December 10, 2024, through December 15, 2024, revealed that the facility did not meet the required PPD hours on December 12, 2024, and December 15, 2024. On December 12, 2024, the facility provided 3.16 PPD hours, and on December 15, 2024, it provided only 2.94 PPD hours. This deficiency was confirmed during an interview with the Nursing Home Administrator on December 16, 2024, who acknowledged the failure to meet the required direct care hours on the specified dates.
Plan Of Correction
1. The facility cannot correct that the state required PPD (per patient daily) minimum hours of 3.20 was not met on 12/12/24 and 12/15/24. 2. The facility scheduler will continue to be educated regarding the state ratios and daily PPD by the NHA/designee. 3. The NHA, DON and scheduler will meet twice a day to review PPD and projected PPD. Nursing supervisors will monitor it on weekends. If the facility is projected to not meet daily PPD, the scheduler or designee will call off duty facility staff and utilize external staffing support resources. 4. NHA/designee will audit staffing daily for three weeks and monthly for three months to ensure daily PPD is being met. Outcomes will be reported to the QA&A committee for review and recommendations.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of Resident R1, who was identified as having a severe cognitive impairment with a BIMS score of 5. Despite having a care plan initiated for the risk of wandering and elopement, the plan was not updated until after the incident occurred. The facility's elopement evaluations previously documented Resident R1 as not being at risk for elopement, and a significant change assessment that included an elopement risk evaluation was not completed. This lack of updated assessments and care plan adjustments contributed to the resident's ability to leave the facility unsupervised. On the day of the incident, Resident R1 was found outside the facility on a highway by a CNA, who brought the resident back. The resident was reportedly attempting to get a cigarette. The incident was confirmed by the Director of Nursing and the Regional Director of Nursing, who acknowledged the failure in supervision. The facility's policies and procedures, as well as the resident's rights, were not adhered to, resulting in the resident's unsupervised exit from the facility.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. F689 1. Resident R1 was safely returned to the facility by nurse aide. Resident R1 was assessed for injuries upon return and no injuries noted. Resident R1 was dressed appropriately for the weather. A new elopement assessment was completed 11/15/24 and wander guard placed on Resident R1. 2. The facility will provide adequate supervision to prevent elopements. Residents are evaluated for elopement risk on admission, readmission and as needed. 3. Facility staff will be re-educated on the wandering and elopement policy by the Director of Nursing/designee. 4. The Interdisciplinary Team (IDT) will meet weekly for four weeks and then monthly for three months to discuss any potential elopement risks with each department including status changes of current residents and new admissions. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Failure to Reassess Elopement Risk for Resident with Cognitive Decline
Penalty
Summary
The facility failed to reassess a resident with cognitive decline for elopement risk, leading to a deficiency. Resident R1, who was diagnosed with dementia and mood disturbance, exhibited a significant decline in cognitive function over several months, as evidenced by a decrease in BIMS scores from 14 and 15 to 5. Despite this decline, the resident's care plan did not include goals or interventions for dementia or cognitive decline, and the facility did not complete a new elopement risk assessment after the resident's cognitive status changed. The resident's clinical records and staff notes indicated ongoing memory problems, confusion, and episodes of anxiety, such as worrying about his truck and attempting to leave the facility to check on it. On one occasion, the resident was found outside the facility on the highway, indicating a clear risk of elopement. Despite these incidents, the facility's elopement evaluations had previously documented the resident as not being at risk for elopement, and a significant change assessment initiated in September was not completed. Interviews with the Director of Nursing and the Regional Director of Nursing confirmed that the facility did not reassess residents with cognitive decline for elopement risk as required. The facility's failure to complete the necessary assessments and update the resident's care plan contributed to the resident's ability to leave the facility unsupervised, posing a potential risk to the resident's safety.
Plan Of Correction
F744 1. The facility cannot correct that Resident R1 was not reassessed for elopement with a cognitive decline until 11/15/24. 2. The Social Service Director/designee will review current residents BIMS to ensure if there was a cognitive decline they were reassessed for elopement. 3. The nursing staff and social service will be re-educated on the policy dementia -clinical protocol by the Director of Nursing/designee. Social Service will notify the interdisciplinary team when there is a change in resident BIMS to ensure resident is reassessed for elopement risk. 4. The Social Service will audit 5 residents BIMS weekly for four weeks and then monthly for three months to ensure if there was cognitive decline the resident was reassessed for elopement. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Facility Fails to Maintain Homelike Environment Due to Water and Structural Issues
Penalty
Summary
The facility failed to maintain a clean and homelike environment on both the ground and first floors, as observed during a survey. Several issues were identified, including lukewarm water in resident bathrooms that required running for extended periods to reach a warmer temperature. This was confirmed by residents and staff, who noted that the water system's inefficiency affected the entire building. Additionally, there were structural issues such as holes in the walls, unfinished plaster, and an HVAC unit improperly installed, which compromised the homelike environment. Further observations revealed a black substance with a musty odor on the ceiling of a shower room, indicating potential mold presence. The Maintenance Director acknowledged the water system's limitations, citing a single water holding tank for the entire building, which led to inconsistent water temperatures. These deficiencies were noted under the Pennsylvania Code sections related to the responsibility of the licensee, management, and resident rights.
Infection Control Deficiency During Dressing Change
Penalty
Summary
The facility failed to maintain proper infection control practices during a dressing change, as observed during a survey. The facility's policy on Dry/Clean Dressings required cleaning the bedside stand before and after the dressing change, placing clean equipment on a clean field, and washing and drying hands thoroughly. However, during an observation, several lapses were noted. A red biohazard bag was improperly placed in the resident's regular garbage can, and the registered nurse (RN) did not wash or sanitize hands before donning clean gloves multiple times throughout the procedure. The bedside table was wiped but not cleared of resident belongings, and a clean barrier was not used for the items placed on it. Personal scissors were cleansed, but the same scissors were used to cut a dirty dressing without being cleansed afterward. The RN also failed to label the dressing with the date, time, and initials as required by the facility policy. Despite the presence of a bathroom with running water and soap in the resident's room, the RN claimed there was nowhere to wash hands. The Director of Nursing confirmed the facility's failure to prevent cross-contamination during the dressing change. These actions and inactions led to a deficiency in infection control practices, as outlined by the relevant Pennsylvania Code sections.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide behavioral health training for ten staff members, including nurse aides, an activities aide, a dietary aide, a housekeeping employee, a registered nurse, and an occupational therapy employee. The deficiency was identified through a review of facility documents and staff interviews, which revealed that none of the ten employees had received the required training on behavioral health. This lack of training was confirmed by the Nursing Home Administrator during an interview. The deficiency is in violation of several Pennsylvania Code regulations related to the responsibility of the licensee, management, and staff development.
Failure to Provide Opportunity for Advance Directives
Penalty
Summary
The facility failed to provide six out of nine residents reviewed with the opportunity to formulate an advance directive, which is a written instruction such as a living will or durable power of attorney for health care. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's policy on advance directives, dated 12/29/23 and 4/9/24, states that residents have the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. The clinical records of residents with various diagnoses, including diabetes, depression, anxiety, high blood pressure, Huntington's Disease, cancer, congestive heart failure, obesity, and chronic pain, were reviewed. For each of these residents, the records did not contain an advance directive or documentation indicating that they were given the opportunity to formulate one. This was confirmed during an interview with Social Worker Employee E6, who acknowledged the absence of such documentation for the residents in question.
Deficiency in Nurse Aide In-Service Training
Penalty
Summary
The facility failed to provide the required 12 hours of annual in-service education for nurse aides within 12 months of their hire date anniversary, as mandated by regulations. This deficiency was identified for five nurse aides, Employees E1, E2, E3, E4, and E5, who each received only 4 hours of in-service training within the specified timeframe. The facility's policy on in-service training, dated 4/9/24 and 12/29/23, requires all staff to demonstrate competency in training topics to enhance residents' quality of life and care. A review of the facility's assessment indicated that staff training should align with their roles and include updates to policies and procedures as needed. However, the education records for the nurse aides showed a shortfall in the required training hours. During an interview, the Nursing Home Administrator confirmed the deficiency, acknowledging that the facility did not meet the 12-hour annual in-service education requirement for the five nurse aides.
Failure to Complete PASARR Level II Evaluation
Penalty
Summary
The facility failed to complete a Level II evaluation for a resident, as required by the Preadmission Screening and Resident Review (PASARR) process. The facility's policy mandates that all residents undergo a Level I screening and, if necessary, a referral for a Level II evaluation in compliance with state and federal regulations. Resident R15, who has been diagnosed with Schizophrenia and bipolar disorder, was identified as needing a Level II evaluation. However, a review of the clinical records and an interview with Social Services Employee E6 confirmed that the referral and completion of the Level II evaluation by a state PASARR representative were not conducted for this resident.
Failure to Notify Physicians and Assess Residents for Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to notify physicians of abnormal capillary blood glucose (CBG) levels and did not assess residents for hyperglycemia and hypoglycemia, affecting two residents. Resident R39, who was readmitted with diagnoses including diabetes, had a CBG of 53 and 477 on separate occasions, but the physician was not notified, and the resident was not assessed for hyper-/hypoglycemia. The care plan interventions, such as monitoring for signs and symptoms of hypoglycemia and providing insulin coverage, were not followed. Similarly, Resident R78, admitted with diagnoses including diabetes, had a CBG of 62 and 416 on different dates. The facility failed to assess the resident for hyper-/hypoglycemia, did not recheck blood sugar levels, and did not notify the physician of these abnormal results. The care plan interventions, which included monitoring for signs and symptoms of hypo and hyperglycemia, were not adhered to. Interviews with LPNs revealed inconsistencies in the actions taken when abnormal CBG levels were detected, such as notifying the doctor and documenting in the medical records. The Director of Nursing confirmed the facility's failure to notify the doctor of changes in condition related to blood glucose for the affected residents.
Inadequate Supervision and Documentation Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and documentation for the bed mobility needs of a resident, resulting in the resident rolling out of bed. The resident, who had diagnoses of diabetes, end-stage renal failure, and intellectual disabilities, required extensive assistance from two or more staff members for bed mobility. However, there was no documented assistance level for bed mobility in the resident's care plan until several months after admission. A progress note indicated that the resident was found lying on the floor with a hematoma on the right side of the head after a CNA attempted to turn the resident for care. The CNA reported that the resident became stiff and rolled out of bed, hitting the head on the nightstand. The incident was witnessed, and the resident was subsequently taken to the hospital for evaluation. A CT scan showed no acute central nervous system findings or fractures, but a small right frontal hematoma was noted. The Director of Nursing confirmed the lack of adequate documentation for the resident's bed mobility needs, which contributed to the incident.
Expired Medical Supplies Not Disposed Properly
Penalty
Summary
The facility failed to properly dispose of expired and/or opened medical supplies in one of the two medication rooms located on the first floor. During an observation, it was noted that the medication room contained 19 Medline triple pack povidone iodine swabsticks, 16 Curad oil emulsion dressings, 16 Dynarex DynaSorb super absorbent dressings, 25 Brava strip paste coloplasts, and one I Medical Devices IM41000 small bore extension set, all of which were past their expiration dates. This was confirmed during an interview with the Nursing Home Administrator, who acknowledged the failure to dispose of these expired supplies appropriately. The deficiency was identified as a violation of 28 Pa. Code: 211.10(c) regarding resident care policies and 28 Pa. Code: 211.12(d)(1)(2)(5) concerning nursing services. The presence of expired medical supplies in the medication room indicates a lapse in the facility's adherence to proper storage and disposal protocols, as required by the regulations.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for five nurse aides. The employees involved were hired on various dates ranging from 1993 to 2020. Upon review, there was no documented evidence that the facility conducted these evaluations annually as required. An interview with the Nursing Home Administrator confirmed that the performance evaluations were not completed for the five employees in question. This deficiency is a violation of the facility's personnel policies and procedures as outlined in 28 Pa. Code 201.19 (2) and 28 Pa Code: 201.20 (a)(b)(c)(d) regarding staff development.
Deficiency in Staff Training Program Implementation
Penalty
Summary
The facility failed to implement and maintain an effective training program for individuals providing services under contractual agreements, as required by their policy. The policy, dated April 9, 2024, mandates the development, implementation, and maintenance of a training program for all new and existing staff, including those under contractual arrangements, consistent with their expected roles. However, during interviews, both the Director of Nursing and the Nursing Home Administrator confirmed that the previous Human Resource Director did not maintain accurate and complete training files. This deficiency was identified during a review of the facility's policy and staff interviews, indicating a lapse in the facility's adherence to its own training policy.
Failure to Provide Communication Training to Direct Care Staff
Penalty
Summary
The facility was found to have failed in providing necessary communication training to all ten direct care staff members reviewed. This deficiency was identified through a review of facility education documents and staff interviews, which revealed that the facility did not offer communication education to its direct care staff. The staff members affected included nurse aides, an activities aide, a dietary aide, a housekeeping employee, a registered nurse, and an occupational therapy employee. Each of these employees' records lacked documentation of training on effective communication. During an interview, the Nursing Home Administrator confirmed the absence of communication training for the direct care staff. This lack of training is a violation of the facility's responsibility under the 28 Pa. Code: 201.14(a) and 201.20(c), which pertain to the responsibility of the licensee and staff development, respectively. The failure to provide this essential training could potentially impact the quality of care and communication within the facility.
Failure to Provide Resident Rights Training
Penalty
Summary
The facility failed to provide training on resident rights to its staff members, as revealed by a review of facility documents and staff interviews. This deficiency affected ten staff members, including nurse aides, an activities aide, a dietary aide, a housekeeper, a registered nurse, and an occupational therapy employee. The facility's education documents did not include any training on resident rights for these employees. During an interview, the Nursing Home Administrator confirmed the lack of Resident Rights training for direct care staff. This failure is a violation of the Pennsylvania Code, specifically sections 201.14(a) and 201.20(c), which pertain to the responsibility of the licensee and staff development, respectively.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to all staff members reviewed. This deficiency was identified through a review of facility documents and staff interviews, which revealed that ten employees, including nurse aides, an activities aide, a dietary aide, a housekeeping employee, a registered nurse, and an occupational therapy employee, did not receive QAPI training. The Nursing Home Administrator confirmed the lack of training for these employees during an interview. This failure is a violation of the 28 Pa. Code: 201.20(a) Responsibility of Licensee and 28 PA. Code: 201.20(c) Staff Development.
Failure to Provide Compliance and Ethics Training
Penalty
Summary
The facility failed to provide training on compliance and ethics for all ten staff members reviewed, including nurse aides, an activities aide, a dietary aide, a housekeeping employee, a registered nurse, and an occupational therapy employee. The review of facility-provided information for each of these employees revealed the absence of training on compliance and ethics. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the lack of such training for the staff members in question.
Failure to Return Personal Possessions in a Timely Manner
Penalty
Summary
The facility failed to ensure the right of a resident to retain personal possessions, as required by their policy. The resident, who had been diagnosed with anxiety and depression, used jewelry making as a therapeutic activity. After being transported to the hospital for an involuntary psychiatric commitment due to suicidal plans and increased behaviors, the resident returned to the facility. However, her personal belongings, which included jewelry making supplies, were not returned to her for four weeks. The delay in returning the resident's belongings was confirmed by the Social Worker, who stated that the facility wanted to ensure the resident would remain in her new room before returning her possessions. The Nursing Home Administrator acknowledged the failure to uphold the resident's rights. The facility's policy allows residents to retain personal possessions unless it infringes on the rights or safety of others, but the delay in returning the resident's belongings was not justified by these criteria.
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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