§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
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Observations:
Based on review of clinical record, review of facility documents, review of policy and procedures, and interview with staff, it was determined that the facility failed to ensure that medications were administered according to physician's instructions and failed to provide treatments according to physician's instructions for one resident (Resident R1)
Review of facility policy on "Administering Medications" reviewed: December 11, 2024, and revised on June 1, 2025, revealed that under section POLICY: Medications shall be administered in a safe and timely manner, and as prescribed. Under section "PROTOCOL":2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions.
3. Medications must be administered in accordance with orders, including any required time frame.6. The individual administering the medication must check the label to verify the right medication, right dosage, right time and right method of administration before giving the medication.
12. The individual administering the medications must sign it out as being administered (or held/refused) per protocol in the electronic health record.
15. If a drug is withheld, refused or given at a time other than the scheduled time, the individual administering the medications shall document in the electronic health record per protocol. The resident's responsible party, if applicable, and Attending Physician will be made aware.
Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on January 28, 2026, with diagnosis of but not limited to Presence of Right Artificial Knee Joint, Radiculopathy of Cervical region (a condition caused by compression or irritation of a nerve in the neck, leading to pain, numbness, or weakness radiating into the shoulder, arm, or hand.)
Review of facility medication audit for Resident R1 revealed the following:
Naproxen Oral Tablet 500 MG (Naproxen) Give 1 tablet by mouth two times a day for arthritis pain with meals-Start Date-01/29/2026 was scheduled to be administered on January 29, 2026, at 8:00AM was administered at 9:23AM.
Lidocaine HCl External Patch 4 % (Lidocaine HCl) Apply to RLE topically one time a day for pain-Start Date-01/29/2026 0900 was scheduled to be administered on January 29, 2026, at 9:00, was documented as administered at 3:36PM.
Diclofenac Sodium External Gel 1 % (Diclofenac Sodium (Topical)) Apply to RLE (right leg) topically four times a day for pain Apply 2gram-Start Date-01/28/2026 was scheduled to be administered on January 29, 2026, at 9:00am, was documented as administered at 3:34PM. Further, 12PM dose was also documented as administered at 3:34PM.
Celebrex Oral Capsule 200 MG(Celecoxib) Give 1 capsule by mouth one time a day for pain for 30 Days-Start Date-01/29/2026 was scheduled to be administered on January 29, 2026, at 9:00AM was administered at 3:35PM.
Review or Resident R1's treatment administration record (TAR) for January 2026, revealed that Remove Mepilex dressing on Right knee per physician orders on 1/31/26. Leave open to air one time only for right TKR (total knee replacement) for 1 Day-Start Date-01/31/2026. There was no documented evidence that the treatment was completed on 1/31/2026.
Saline Solution (Soft Lens Products) Apply to right knee topically every 4 hours as needed for wound care Cleanse Right knee incision with NSS (normal saline solution), pat dry and cover with Bordered Gauze Dressing Daily and PRN (as needed) for soiling-Start Date -01/31/2026. There was no documented evidence that the treatment was completed on January 31, 2026.
Interview with Regional Nurse, Employee E2 confirmed that the above medications were administered late.
28 Pa Code 211.10(c) Resident care policies
28 Pa. Code 211.12 (d)(1) Nursing services
| | Plan of Correction - To be completed: 03/23/2026
1. Employee involved in late administration of medication on 1/28, 1/29 was educated and disciplined
Employee involved in not documenting the completion of the treatment was educated and disciplined
2. A two- week look back was conducted on new admissions with pain management and/or treatment orders, identifying areas of concern, notification, and education.
3.Licensed nursing staff were re-educated on the facility's policy regarding medication and treatment administration passes.
4.DON or DON Designee will complete weekly audits, x 4weeks of various residents' medication and treatment administration passes to ensure adherences to the MD order, and regulatory compliance with appropriate documentation and notification. The results of the audits will be reviewed during the monthly QAPI meeting. The QA committee will determine the need for continued monthly auditing.
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