§ 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 records and staff interviews, it was determined that the facility failed to ensure physician's orders were followed for four of 35 residents reviewed. (Resident 4, Resident 6, Resident 71 and Resident 181).
Findings Include:
Review of Resident 4's diagnosis list revealed diagnoses including Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment), morbid obesity, osteoarthritis (inflammation of the joint) and right below knee amputation.
Review of Resident 4's physician orders revealed an order for Hydrocodone-Acetaminophen 5-325 milligram (mg) (narcotic pain medication) to be administered every eight hours as needed for severe pain 5-10 level.
Review of Resident 4's September Medication Administration Record (MAR) revealed that on September 16, 2025, September 17, 2025, and September 26, 2025, Resident 4 received Hydrocodone-Acetaminophen 5-325 mg for pain levels of zero.
Review of Resident 4's October 2025 MAR revealed that on October 1, 2025, and October 3, 2025, Resident 4 received Hydrocodone-Acetaminophen 5-325 mg for pain levels of zero.
The above information was conveyed to the Nursing Home Administrator on October 20, 2025, at 10:00 a.m.
Resident 6 was admitted to the facility on May 17, 2024, with admitting diagnoses of hemiplegia and hemiparesis (weakness and inability to move on side of the body) following other non-traumatic intracranial hemorrhage affecting the left dominant side (stroke), and muscle weakness.
Review of Resident 6's clinical record revealed an active order for " Oxycodone HCl (narcotic pain medication) Oral Tablet 5 mg - Give one (1) tablet by mouth every six (6) hours as needed for severe pain (7-10) " with a start date of June 19, 2024.
Review of Resident 6's Medication Administration Record (MAR) for the months of April through November 2025 (eight months) revealed that the medication was administered outside the written parameters a total of 101 times.
During an interview with the Director of Nursing (DON) on October 20, 2025, at 11:50 a.m., the DON confirmed that staff administered the above pain medication outside of the physician ' s written parameters.
Review of Resident 71's diagnosis list revealed diagnoses of but not limited to chronic kidney disease, stage 3 (kidneys have mild to moderate damage) and congestive heart failure (CHF - excessive body/lung fluid caused by a weakened heart muscle).
Review of Resident 71's physician's order of October 6, 2025, indicated a fluid restriction of 1800 mL (milliliters) per day. Review of nutrition note of October 6, 2025, revealed 1800 mL total in 24 hours with the following breakdown: Nursing 990 mL/24 hr (330 mL on 7-3, 330 mL on 3-11 and 330 mL on 11-7) and Dietary 810 mL/24 hr (330mL at breakfast, 240 mL at lunch, and 240 mL at dinner).
Further review of Resident 71's clinical record failed to reveal evidence that the dietary fluid restriction was being monitored to ensure that the fluid restriction was being followed according to physician ' s orders.
Review of Resident 181's clinical record revealed diagnoses including but not limited to end stage renal disease (ESRD- failure of kidney function to remove toxins from blood) and dementia (general loss of cognitive abilities, including memory).
Review of Resident 181's physician orders dated April 30 2025 revealed an order for Fluid restriction: 32 ounces per day(945ml) 945 mL Total in 24 hrs; Nursing:350 ml/24hr, (100 ml on 7-3, 150 ml on3-11, 100 ml on 11-7) Dietary: 595ml/24hr (355 ml @Breakfast, 120 ml@ Lunch, 120 ml @Dinner) three times a day.
Review of Resident 181's clinical record including May, June, July, August, September and October 2025 Medication Administration Record (MAR) failed to reveal evidence that nursing was monitoring Resident 181's total daily fluid intake in conjunction with the Dietary department.
Interview with the Nursing Home Administrator on October 20, 2025, at 12:20am confirmed the above.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(d)(1) Nursing Services
| | Plan of Correction - To be completed: 11/18/2025
This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report.
1. The center cannot retroactively correct the alleged deficient practice. R4, R6, R71, and R181 had no adverse reactions related to alleged deficient practice.
2. The center completed a 7-day look back audit of residents with as needed Hydrocodone-Acetaminophen and as needed Oxycodone pain medication orders to validate medications were administered as ordered. The completed a 7-day look back audit of residents with a fluid restriction to validate their fluids were monitored per physicians orders. All variances were addressed on the facility audit tool.
3. Licensed professionals were educated following physicians orders as written for administration of as needed pain medications and monitoring of fluid intake for residents with a fluid restriction.
4. The Director of Nursing or Designee with audit 10 residents records weekly for 4 weeks followed by 10 residents records monthly for 2 months to ensure as needed Hydrocodone-Acetaminophen and as needed Oxycodone are being administered per physicians orders. The Director of Nursing or designee will audit 10 residents records weekly for 4 weeks followed by 10 residents records monthly for 2 months to ensure residents with a fluid restrictions fluid intake is being properly monitored. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations as need. Further audit frequency will be determined based on audit findings.
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