395697
04/01/2025
Embassy of Woodland Park
18889 Croghan Pike Orbisonia, PA 17243
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm or potential for actual harm
Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for one of five residents reviewed (Resident 4).
Residents Affected - Few
Findings include: The facility's policy regarding medication administration, dated March 13, 2025, indicated that medications are to be administered by licensed nurses in accordance with professional standards. Staff are to compare the medication source (bubble pack, vial, etc) with the Medication Administration Record (MAR) to verify the resident name, medication name, form, dose, route, and time. The staff are to observe resident consumption of the medication. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated February 2, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had constipation and dementia. A care plan for Resident 4, dated April 29, 2024, revealed that the resident was at risk for constipation and complained of gas pains at times. Staff were to administer medications as ordered by the physician. Physician's orders for Resident 4, dated September 10, 2024, included an order for the resident to receive 8.6-50 milligrams of senna-docusate sodium (stool softening medication) with instructions to give three tablets by mouth once time a day for constipation at 8:00 p.m. Observations of Resident 4 on April 4, 2025, at 4:24 p.m., revealed that she was lying down in bed, and there was a medication cup with three red pills and a cup of water on the over-bed table. Resident 4 sat up and took the pills. Interview with Licensed Practical Nurse 1 on March 1, 2025, at 4:47 p.m. confirmed that she left the medication at bed side, and it was to be administered in the evening. She identified the medication as senna-docusate. Interview with the Director of Nursing on April 1, 2025, at 5:17 p.m. confirmed that licensed staff responsible for medication administration should administer the medication at the physician-ordered time. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.
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395697
395697
04/01/2025
Embassy of Woodland Park
18889 Croghan Pike Orbisonia, PA 17243
F 0761
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to store medication appropriately for one of five residents reviewed (Resident 4).
Findings include: The facility's policy regarding medication administration, dated March 13, 2025, indicated that medications are to be administered by licensed nurses in accordance with professional standards. Staff are to compare the medication source (bubble pack, vial, etc) with the Medication Administration Record (MAR) to verify the resident name, medication name, form, dose, route, and time. The staff are to observe resident consumption of the medication. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated February 2, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had constipation and dementia. A care plan for Resident 4, dated April 29, 2024, revealed that the resident was at risk for constipation and complained of gas pains at times. Staff were to administer medications as ordered by the physician. Physician's orders for Resident 4, dated September 10, 2024, included an order for the resident to receive 8.6-50 milligrams of senna-docusate sodium (stool softening medication) with instructions to give three tablets by mouth once time a day for constipation at 8:00 p.m. Observations of Resident 4 on April 4, 2025, at 4:24 p.m. revealed that she in room [ROOM NUMBER] bed A on the locked memory unit of the facility. She was lying down in bed, and there was a medication cup with three red, round tablets and a cup of water on the over-bed table. Resident 4 sat up and took the pills. Interview with Licensed Practical Nurse 1 on March 1, 2025, at 4:47 p.m. confirmed that she left the medication at bed side and she should not have. Interview with the Director of Nursing on April 1, 2025, at 5:07 p.m. confirmed that licensed staff responsible for medication administration should remain with the resident and observe the resident ingest the medication, and not leave it at bedside. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1) Nursing Services.
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