Park Lane Post Acute Llc
Inspection Findings
F-Tag F0755
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a
review of clinical and pharmacy records and staff interviews, it was determined that the facility failed to ensure medications were made available for one of the two residents reviewed (Resident CL1).Findings include: Clinical records review revealed Resident CL1 was admitted to the facility on [DATE REDACTED], with a diagnosis of T11-T12 compression fracture. A review of the Physician's order (POS) dated November 26, 2025, revealed Lyrica (A medication used to treat nerve pain and seizures) 25 mg one capsule by mouth three times daily. The medication was scheduled at 9:00 a.m., 1:00 p.m., and 9:00 p.m. A review of the November 2025 Medication Administration Record (MAR) revealed that Resident CL1 was not administered Lyrica on November 27, 2025, at 9:00 a.m., 1:00 p.m., and 9:00 p.m. A review of the nursing progress notes dated November 27, 2025, at 10:39 a.m., revealed Lyrica medication not yet in from pharmacy. A review of the nursing progress notes dated November 27, 2025, at 12:12 p.m., revealed Lyrica medication Not here from pharmacy, not available in Pixis. (An automated medication dispensing system).
A review of the nursing progress notes dated November 27, 2025, at 11:07 p.m., revealed Lyrica medication waiting for pharmacy to deliver. A review of the pharmacy records, delivery report revealed Lyrica medication was not delivered to the facility until November 28, 2025, which resulted in Resident CL1 missing three doses of the medication. Clinical records review failed to reveal that the physician was notified of the missed medications. A review of the POS dated November 25, 2025, revealed an order for Hydrocodone-Acetaminophen (A medication used to treat moderate to severe pain) 7.5-325mg, give one tablet every four hours for back pain. A review of December 2025, MAR revealed Hydrocodone-Acetaminophen was not administered to Resident CL1 on December 8, 2025, at 8:00 a.m. A
review of the nursing progress notes dated December 8, 2025, 10:17 a.m., revealed medication administered approximately 11:15 a.m., delayed due to unavailability. An interview with the Director of Nursing on January 2, 2026, at 1:00 p.m., confirmed that the above medications were not administered to Resident CL1 due to unavailability from the pharmacy. The facility failed to ensure Resident CL1's pain medications were made available for the resident for administration. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
PARK LANE POST ACUTE LLC in WEST CHESTER, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WEST CHESTER, PA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PARK LANE POST ACUTE LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.