§ 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 clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of 11 sampled residents. (Resident 5)
Findings include:
Clinical record review revealed that Resident 5 had diagnoses that included dementia, gastro-esophogeal reflux disease, and protein calorie malnutrition. A physician's order dated February 17, 2025, directed staff to administer a medication for abdominal bloating and gas (simethicone) before meals and at bedtime at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9:00 p.m. A physician's order dated July 30, 2026, directed staff to administer a medication for irritable bowel and abdominal cramping (dicyclomine hydrochloride) with meals at 7:30 a.m., 11:30 a.m., and 4:30 p.m.
Observations on August 4, 2026, from 11:30 p.m., through 1:22 p.m., revealed Resident 5 was in the dining room participating in an activity and waiting for her lunch to be served. From 1:23 p.m. to 1:45 p.m., staff assisted Resident 5 with her lunch meal. The prescribed medications were still not administered when the resident finished eating her meal, over two hours after the scheduled administration times.
In an interview on August 4, 2026, at 1:55 p.m., the licensed practical nurse (LPN 1) stated that Resident 5's scheduled medications were to be given prior to and with meals, but LPN 1 had not given them.
In an interview on August 4, 2026, at 2:20 p. m., the Director of Nursing confirmed the medications should have been given as ordered.
CFR 483.25 Quality of care
Previously cited 1/29/26.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
| | Plan of Correction - To be completed: 09/01/2026
Resident 5 received her medications as ordered by physician. Physician/CRNP made changes to R5's orders and times of administration. LPN 1 was educated on medication administration and following physician orders.
Current residents with orders for simethicone and/or dicyclomine hcl administration at specific times before and during meals were reviewed and any necessary changes were made with physician review.
Current Facility Nurses were educated by the Nurse Practice Educator/designee on medication administration of medications ordered prior to and with meals per physician orders.
Random audits of medication administration records are completed to ensure that residents are receiving medications ordered before and with meals correctly per physician orders. Auditing occurrence will be weekly x4 weeks, monthly x1 month.
Auditing results will be reviewed in QAPI, trends identified, and corrective actions will be implemented as needed to ensure compliance.
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