§ 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 facility policy, clinical records, and staff interviews, it was determined that the facility failed to administer medications in accordance with professional standards of practice and physician recommendations for three of four residents reviewed (Residents R4, R7, and R10).
Findings include:
Review of a facility policy entitled "Administering Medications" dated 1/5/26, revealed that medications are administered in accordance with prescriber orders, including required timeframe, and that medications are administered within one hour of their prescribed time, unless otherwise specified (before and after meals).
Resident R4's clinical record revealed an admission to the facility on 3/11/26, with diagnoses that included Diabetes (a health condition caused by the body's inability to produce enough insulin), Hyperlipidemia (high cholesterol), and high blood pressure.
Resident R4's physician's orders revealed an order dated 5/23/26 for Insulin Glargine Solution (a type of long-acting insulin to control blood sugar in a person who is diabetic) 100 units/ML(milliliter) Inject 20 units subcutaneously (medication is injected into the fatty tissue beneath the skin) one time a day for diabetes. Further review of the medication order revealed to administer the insulin at 8:30 a.m. The August 2026 Medication Administration Record (MAR) revealed the Insulin was administered more than one hour late on: 8/3/26 at 1:21 p.m., 8/4/26 at 1:25 p.m.,8/5/26 at 2:49 p.m., 8/6/26 at 1:43 p.m., 8/7/26 at 2:39 p.m., 8/8/26 at 2:10 p.m., 8/9/26 at 2:14 p.m., 8/10/26 at 1:29 p.m., 8/12/26 at 1:22p.m.,8/13/26 at 12:31 p.m., 8/14/26 at 1:13 p.m., 8/17/26 at 1:07 p.m., 8/18/26 at 1:02 p.m., 8/19/26 at 12:30 p.m., 8/21/26 at 1:27 p.m., 8/22/26 at 1:03 p.m., 8/23/26 at 1:49 p.m., 8/24/26 at 1:27 p.m., 8/26/26 at 1:21 p.m., 8/27/26 at 11:48 a.m., 8/28/26 at 1:19 p.m., and 8/31/26 at 1:10 p.m.
Resident R7's clinical record revealed an admission to the facility on 8/15/24, with diagnoses that included Diabetes, End Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), and high blood pressure.
Resident R7's physician's orders revealed an order dated 5/8/26 for Insulin Glargine Solution 100 units/ML Inject 7 units subcutaneously one time a day for diabetes. Further review of the medication order revealed to administer the insulin at 8:00 a.m. The August 2026 MAR revealed the Insulin was given more than one hour late on: 8/3/26 at 12:47 p.m., 8/4/26 at 12:30 p.m.,8/5/26 at 1:28 p.m., 8/6/26 at 11:09 a.m., 8/7/26 at 1:09 p.m., 8/8/26 at 12:55 p.m., 8/9/26 at 12:00 p.m., 8/10/26 at 11:47 a.m., 8/11/26 at 10:57 a.m.,8/12/26 at 11:32 a.m., 8/13/26 at 11:46 a.m., 8/14/26 at 11:47 a.m., 8/18/26 at 12:35 p.m., 8/19/26 at 11:18 a.m., 8/20/26 at 10:40 a.m., 8/21/26 at 12:37 p.m., 8/22/26 at 12:23 p.m., 8/23/26 at 12:41 p.m., 8/24/26 at 12:55 p.m., 8/26/26 at 12:47 p.m., 8/27/26 at 11:34 a.m., 8/28/26 at 12:43 p.m., and 8/31/26 at 12:46 p.m.
Resident R10's clinical record revealed an admission to the facility on 3/25/26, with diagnoses that included gastro-esophageal reflux disease (GERD-a condition where stomach acid flows back into the esophagus [tube that passes food from the mouth into the stomach]), Hyperlipidemia, and high blood pressure.
Resident R10's physician's orders revealed an order dated 8/4/26 for Lidocaine External Patch 4% apply to bilateral knees topically (to the skin) one time a day for bilateral knee pain, Cut one patch in half and apply to each side of dressing on right knee and remove per schedule. Further review of the medication order revealed to apply the patch at 8:00 a.m. and to remove at 8:00 p.m. The August 2026 MAR revealed the Lidocaine patch was applied more than one hour late on: 8/6/26 at 1:11 p.m., 8/7/26 at 12:21 p.m., 8/8/26 at 11:00 a.m., 8/9/26 at 2:32 p.m., 8/10/26 at 9:42 a.m., 8/23/26 at 2:29 p.m., 8/24/26 at 11:42 a.m., 8/28/26 at 12:58 p.m., 8/29/26 at 11:17 a.m., 8/30/26 at 1:14 p.m., and 8/31/26 at 12:30 p.m.
During a phone interview on 9/02/26, at 1:30 p.m. the Director of Nursing confirmed that the above listed medications were administered late.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 10/06/2026
"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."
The facility cannot correct that resident R4, resident R7, and resident R10 received medications more than one hour late. There were no adverse resident affects.
The Director of Nursing/Designee will review medication administration workflows, including medication-pass schedules, staffing patterns, and the volume of medications scheduled during peak administration times, to identify opportunities to improve timely medication administration. Findings will be reviewed with facility Medical Director and changes made as recommended.
All licensed nursing staff will be re-educated on the Medication Administration Policy.
The Director of Nursing/Designee will audit medication administration records to verify medications are administered within the prescribed timeframe. Audits will be completed on 5 residents, 3 times per week for 4 weeks, then weekly for 2 weeks, and monthly for 2 months.
Outcomes of audits will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
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