Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oakwood Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to store milk in accordance with food safety standards. During a kitchen tour, surveyors observed a broken gasket on the milk cooler and a broken thermometer, preventing the cooler temperature from being determined. Two milk cartons checked by the District Manager both read 50 degrees Fahrenheit, above the USDA cold food standard of 40 degrees Fahrenheit.
Safe and appropriate respiratory care was not provided for a resident with chronic respiratory failure with hypoxia, epilepsy, trach, and dysphagia. The resident had an order for oxygen at 5 L/min via trach continuously, but staff observed the oxygen set at 1.5 liters and later at 4 liters, both inconsistent with the physician’s order.
Medication Refrigerator Temperature and Maintenance Deficiencies: The medication room refrigerator was observed with temperatures outside the required 36-41 degree range on two of three days reviewed, and staff did not notify maintenance or remove/quarantine exposed meds. The freezer compartment also had about five inches of ice buildup, and the unit was not defrosted as required.
Failure to Follow Enhanced Barrier Precautions During Resident Care: A resident with a trach, PEG tube, Foley catheter, and ESBL history had an order for EBP, but staff did not wear the required gown and gloves during direct care. During a transfer, CNAs and an LPN wore gloves only while assisting with the resident’s trach, oxygen, and feeding tube, and on another occasion an LPN provided trach care without an appropriate PPE gown; the UM and DON confirmed the lapse.
A resident with significant mobility issues experienced an unwitnessed fall, later reporting right femur pain and requiring hospital admission for a femur fracture. Despite these events, the care plan addressing fall interventions was not updated promptly, with new interventions scheduled to begin months after the incident. The DON confirmed the delay in updating the care plan following the fall.
A resident with a left femur fracture received frequent doses of opioid pain medication without being offered or provided any non-pharmacological pain interventions, contrary to facility policy. The DON confirmed that non-pharmacological measures were not implemented prior to pharmacological treatment.
A nurse aide transported a resident on respiratory isolation without wearing a gown or eye protection, and the resident was not provided with a facemask while outside their room. The aide also assisted the resident in their room without the required PPE, contrary to facility policy and CDC guidelines.
Two residents with significant care needs reported being left in urine for extended periods, and their allegations of neglect were not promptly reported to the DON or state authorities as required by facility policy. Staff were aware of the reporting requirements but failed to escalate the concerns, resulting in non-compliance with state regulations.
Multiple residents with physical and cognitive impairments did not receive timely assistance with toileting hygiene and grooming, including long waits for incontinence care, unaddressed facial hair, and long nails, as confirmed by staff, family, and resident council feedback. Staff sometimes turned off call bells without providing care, especially during shift changes and meal service.
A resident with multiple medical conditions was admitted with physician orders for scheduled and sliding scale insulin administration. The facility did not implement or administer the sliding scale insulin as ordered until several days after admission, as confirmed by review of the MAR and staff interviews. There were no documented changes to the insulin orders during this period.
A resident with a history of stroke, Parkinson's, and dementia was administered Acetaminophen for a fever, but the administration was not documented in the medication record. The LPN confirmed the oversight, and the DON acknowledged the incomplete documentation.
The facility failed to provide adequate nursing staff, resulting in care deficiencies for several residents. A resident reported a non-functioning call bell and delays in receiving care due to staffing shortages. Another resident remained in bed past their usual time due to insufficient staff to assist with transfers. Additionally, a resident missed a cataract surgery appointment because no staff was available to accompany them. The dining room was unsupervised, and residents had to eat in their rooms due to staffing shortages.
The facility failed to maintain the confidentiality of residents' medical information on Unit A. On two occasions, medication carts assigned to nurses were left unattended with computer screens open, displaying identifiable resident information. The incidents were confirmed by staff, including an Infection Preventionist and an Administrator, highlighting a breach in confidentiality as required by regulations.
A resident with schizophrenia and other conditions experienced an unintentional overdose of oxycodone and baclofen, leading to hypercapnic respiratory failure. Despite the resident's report of receiving too much narcotic medication, the facility did not investigate or report the incident to the State survey agency, as confirmed by the Nursing Home Administrator and DON.
A facility failed to create a person-centered care plan for a resident at risk of elopement, who had removed a wanderguard from their wheelchair. Despite the resident's aggressive behavior and verbal threats to leave, the care plan did not address these risks. The DON confirmed the lack of a comprehensive care plan.
A resident with cognitive intactness and multiple health conditions did not receive timely myringotomy treatment and cataract surgery due to communication lapses and staffing shortages. Despite recommendations for these treatments, the facility delayed scheduling appointments, leading to the resident's continued hearing and vision impairments.
A resident with mental health diagnoses was assessed as an elopement risk, but the facility failed to complete an Elopement Risk Evaluation. Despite a physician's order for a wander guard, the resident removed it, and staff confirmed no alternative interventions were explored. The resident had attempted to elope in the past 30 days, highlighting the ineffectiveness of the current measures.
A resident with a tracheostomy did not receive appropriate care due to missing supplies and delayed attention. The required trach tube was unavailable, and a wet trach collar was not changed promptly after a shower. Additionally, during a tracheostomy treatment, a disposable inner cannula was not readily available, requiring retrieval from storage. These issues were confirmed by the Infection Preventionist and DON.
A facility failed to ensure an attending physician addressed a pharmacist's identified irregularity in a resident's medication regimen. The resident, with multiple diagnoses including depression and dementia, was prescribed Trazadone without a specified duration, contrary to CMS regulations. Despite the pharmacist's recommendation, there was no documentation by the physician regarding the medication's continued use or potential adverse effects.
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents, leading to deficiencies in infection prevention and control. A resident with MRSA did not have the required red dot on their door, and a nurse provided wound care without EBP. Another resident with a red dot indicating EBP was not treated with the precautions, as the nurse was unaware of the requirement. Additionally, a resident requiring EBP for tracheostomy treatments did not receive care with the necessary precautions.
The facility did not ensure that the Department of Health Survey results were accessible to residents and visitors. Residents were unaware of the survey results binder and its location. Observations confirmed that the binder was placed behind desks, making it inaccessible. The Nursing Home Administrator acknowledged the issue.
A resident's request to not have a specific nurse administer medications was ignored, with the nurse continuing to provide care on 44 occasions over three months. This violated the resident's right to choose their healthcare provider, as outlined in their care plan.
Milk Cooler Temperature Control Failure
Penalty
Summary
The facility failed to ensure beverages were stored in accordance with food service safety standards. During a tour of the main kitchen with the Food Service Director and District Manager, the milk cooler was observed with a broken gasket that was needed to maintain an airtight seal and keep the milk at the correct temperature. The cooler was fully stocked with a fresh delivery of individual milk cartons reportedly delivered at approximately 8:00 a.m., and the thermometer inside the milk box was broken, so the temperature of the cooler could not be determined. The District Manager then checked two milk cartons, one from the top and one from the bottom, and both were 50 degrees Fahrenheit. USDA guidance reviewed by surveyors stated cold food should be kept at or below 40 degrees Fahrenheit and identified 40 to 140 degrees Fahrenheit as the danger zone.
Inconsistent Oxygen Delivery for a Resident with a Tracheostomy
Penalty
Summary
Safe and appropriate respiratory care was not provided for one resident with chronic respiratory failure with hypoxia, epilepsy, tracheostomy, and dysphagia. The resident had a physician’s order dated January 23, 2026, to administer oxygen at 5 liters per minute via trach continuously, and the care plan last revised on January 26, 2026, directed oxygen as ordered via trach mask. During an observation on May 4, 2026, a licensed nurse confirmed the resident’s oxygen was set at 1.5 liters, which did not match the ordered rate. During another observation on May 5, 2026, the unit manager confirmed the resident’s oxygen was set at 4 liters, which was also inconsistent with the physician’s order for 5 liters continuously.
Medication Refrigerator Temperature and Maintenance Deficiencies
Penalty
Summary
Medications in the medication room refrigerator were not stored within the required temperature range of 36-41 degrees, as the temperature log showed that the refrigerator exceeded the acceptable range on two of three days reviewed. During observation with the Nurse Manager, the facility also had approximately five inches of ice accumulation in the freezer compartment. Staff did not notify maintenance about the temperature variance or the excessive ice buildup, and medications exposed to the out-of-range temperatures were not removed or quarantined. The refrigerator was also not defrosted as required by the facility's temperature log instructions.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for Resident R2, who had diagnoses including chronic respiratory failure with hypoxia, epilepsy, tracheostomy, and dysphagia. R2 also had physician orders for suctioning the tracheostomy, changing trach ties every shift, and maintaining transmission-based precautions with Enhanced Barrier Precautions due to a trach, Foley catheter, PEG tube, and history of ESBL in the urine. Facility policy stated that an Enhanced Barrier Precautions order should be entered, signage posted, a red dot placed on the resident’s door tag, and staff should adhere to the precautions during care. During an observation, a sign outside R2’s room indicated Enhanced Barrier Precautions were required, but staff providing direct care did not follow the required PPE use. Three staff members assisting with transfer of R2 from bed to wheelchair wore gloves only and did not wear gowns while handling the resident, and a licensed nurse assisted with the tracheostomy, oxygen, and feeding tube during the transfer. The nurse also unhooked the trach and disconnected the feeding tube to facilitate the transfer. On another observation, a licensed nurse providing tracheostomy care to R2 was not wearing an appropriate PPE gown, and both the Unit Manager and DON confirmed that the nurse was not wearing appropriate PPE during that care.
Failure to Timely Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure timely revision of a resident's care plan following a fall incident. Clinical documentation showed that a resident with diagnoses including muscle wasting, difficulty walking, atrophy, and muscle weakness was readmitted to the facility and subsequently experienced an unwitnessed fall. The resident complained of right femur pain the day after the fall and was later admitted to the hospital with a right femur fracture. Despite these events, the resident's fall care plan was not initiated until over two months after the incident, and specific interventions such as assistance out of bed and monitoring for toilet needs were not scheduled to begin until even later. An interview with the DON confirmed that the care plan was not updated in a timely manner after the fall, contrary to facility policy requiring prompt care plan revisions when a resident's condition changes.
Failure to Implement Non-Pharmacological Pain Interventions
Penalty
Summary
The facility failed to implement non-pharmacological interventions for pain management as required by its own policy and professional standards. Review of the facility's Pain Evaluation and Management Policy indicated that care plans should include both pharmacologic and non-pharmacologic interventions, and that these plans should be reviewed and revised as needed. For one resident with a left femur fracture, the care plan did not include any non-pharmacological interventions for pain, despite the resident being at risk for pain related to the fracture. Clinical records showed that the resident was prescribed and received multiple doses of oxycodone for severe pain, but there was no documented evidence that non-pharmacological interventions were offered or provided. The Medication Administration Record confirmed frequent administration of opioid medication, and the Director of Nursing acknowledged that non-pharmacological interventions were not being used for this resident, despite facility policy requiring such measures prior to pharmacological interventions.
Failure to Follow PPE Protocols for Resident on Respiratory Isolation
Penalty
Summary
The facility failed to follow established infection control practices regarding the use of personal protective equipment (PPE) for residents on transmission-based isolation precautions. Facility policy and CDC guidelines require staff to use N95 masks, gowns, and eye protection when caring for residents with COVID-19 or those on respiratory isolation, and to ensure residents wear a facemask when leaving their rooms. During observation, a nurse aide was seen transporting a resident on respiratory isolation without wearing a gown or eye protection, and the resident was not provided with a facemask while in the hallway. Further observation showed the same aide assisting the resident inside the room without the required PPE. The unit manager confirmed that the resident was on respiratory isolation and that staff should have been using N95 masks, goggles or eye wear, and gowns, and that residents should wear an N95 mask when outside their room. These actions were not consistent with facility policy or CDC guidelines, resulting in a deficiency related to infection prevention and control.
Failure to Timely Report Allegations of Neglect to State Authorities
Penalty
Summary
The facility failed to ensure that all allegations of abuse and neglect were reported immediately to the Pennsylvania Department of Health for two residents. According to facility policy, any allegation of abuse must be reported to the Administrator of Nursing immediately, and an investigation must be initiated without delay. In the case of one resident with muscle wasting, heart failure, and mobility issues, the resident reported being left wet with urine for several hours overnight and informed the morning charge nurse, who did not escalate the report to the Director of Nursing as required. The Director of Nursing was unaware of the allegation until informed by a surveyor. For another resident with muscle wasting, failure to thrive, and an above-knee amputation, both the resident and her family reported that concerns about being left in urine for an extended period were communicated to nursing staff but not reported to administration. The Unit Manager acknowledged awareness of the neglect allegation but did not report it to the Director of Nursing. Staff interviews confirmed knowledge of the reporting requirement but revealed that the allegations were not reported due to distractions such as surveyor presence. These failures resulted in non-compliance with state regulations regarding timely reporting of suspected abuse and neglect.
Failure to Provide Timely Assistance with ADLs and Grooming
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically in maintaining proper grooming and timely toileting hygiene, for five residents with varying degrees of physical and cognitive impairment. One resident, who was cognitively intact but required moderate assistance, reported waiting three hours after pressing the call bell at night before being changed out of wet clothing. Another resident, with moderate cognitive impairment and Parkinson's disease, was observed to have facial hair on the chin, which was confirmed by a licensed nurse. A resident with severe cognitive impairment and a contracture was observed to have long nails, despite a care plan specifying routine nail care, and the family expressed a desire for the nails to be kept short. Another resident, also severely cognitively impaired and with a recent arm fracture, was found with long nails and expressed a wish for them to be cut, which was confirmed by a nurse. Additionally, a resident with an above-knee amputation and muscle wasting, who required maximal assistance, reported being left in urine for approximately two hours during breakfast, with staff delaying care due to meal service duties. The resident also experienced a delay in care when a nursing aide was unsure of her assignment and turned off the call bell without providing assistance. Resident council feedback indicated that call bells were sometimes turned off by aides without providing care, particularly during shift changes and the evening shift. Family interviews corroborated delays in care, with one family member reporting that a resident was left in urine until after breakfast trays were collected. These findings were confirmed by staff interviews and observations, demonstrating a pattern of inadequate assistance with ADLs and grooming for multiple residents.
Failure to Follow Physician Orders for Sliding Scale Insulin Administration
Penalty
Summary
A deficiency occurred when the facility failed to follow physician orders regarding medication administration for a resident admitted with diagnoses including adult failure to thrive, muscle wasting and atrophy, acquired absence of the left leg above the knee, and muscle spasm. The resident was cognitively intact, as indicated by a BIMS score of 15. Upon admission, the resident had a physician order for Insulin Aspart Flex Pen to be administered before meals, with specific dosing instructions and a sliding scale for blood glucose management, as documented in the hospital discharge orders. Despite these clear orders, the facility did not create or administer the sliding scale insulin order until several days after admission. The Medication Administration Record (MAR) for the relevant month did not reflect the sliding scale insulin order or its administration until five days post-admission. Interviews with the Unit Manager and the Director of Nursing confirmed that the facility failed to implement the physician's sliding scale insulin order upon admission, and there were no documented changes to the insulin orders by the facility's physician during this period.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure complete and accurate medication administration for one of the residents, identified as Resident CR1. The facility's policy on administering medication requires that the individual administering the medication records specific details in the resident's medication record, including the date and time of administration, dosage, route, and other relevant information. However, a clinical record review revealed that the administration of Acetaminophen to Resident CR1 was not documented in the medication administration record, despite being noted in a clinical progress note by a licensed nurse, Employee E6. Resident CR1, who had diagnoses including sequelae of cerebral infarction, Parkinson's disease, and dementia with behavioral disturbance, was admitted to the facility and later expired. On a specific date, the resident had a temperature of 100.3°F, and Acetaminophen was administered to reduce the fever, which decreased to 99.1°F. Despite this, the administration was not recorded in the medication administration record. An interview with Employee E6 confirmed the failure to document the administration, and the Director of Nursing, Employee E2, also confirmed the incomplete documentation.
Staffing Shortages Lead to Care Deficiencies
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in several deficiencies. Resident R78 reported that the call bell was not functioning, leading to delays in receiving care, and was found to be wet and in need of assistance with activities of daily living. The facility was short-staffed, with only three nursing assistants and two nurses for 44 residents, some of whom required assistance from two staff members or the use of lifts. Additionally, the dining room was left unsupervised during meal times, and residents were required to eat in their rooms due to staffing shortages. Resident R100 experienced delays in being assisted into his wheelchair, remaining in bed past his usual time due to staffing shortages. Resident R32 missed a cataract surgery appointment because there was no staff available to accompany her. On another occasion, all nursing aides were observed having breakfast, leaving no staff present on the A wing, and the assignment sheet had not been completed to allocate specific room coverage. These incidents highlight the facility's failure to ensure sufficient nursing staff to meet the residents' needs, impacting their physical, mental, and psychosocial well-being.
Confidentiality Breach of Residents' Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information on one of its nursing units, specifically Unit A. During an observation on August 26, 2024, at 12:50 p.m., the Infection Preventionist, Employee E3, confirmed that a medication cart assigned to licensed nurse, Employee E5, was left unattended with the computer screen open, displaying identifiable resident information. Employee E3 was not present in the hallway or near the medication cart. Later, at 2:25 p.m. the same day, the licensed wound nurse, Employee E8, confirmed the same issue with the medication cart assigned to Employee E5, again left unattended with the screen open. Employee E5 was not in the vicinity. On August 29, 2024, at 11:44 a.m., an Administrator, Employee E1, confirmed a similar observation on A wing, where a medication cart assigned to registered nurse, Employee E13, was left unattended with the computer screen open, exposing resident information. Employee E13 was not nearby. During an interview on August 29, 2024, the Nursing Home Administrator acknowledged the facility's failure to maintain the confidentiality of residents' medical information as required by 28 Pa Code 211.5(b) Medical records.
Failure to Investigate and Report Unintentional Overdose
Penalty
Summary
The facility failed to investigate an allegation of possible abuse and neglect and report the results to the State survey agency for a resident who experienced an unintentional overdose. The resident, diagnosed with schizophrenia, major depression, muscle spasticity, low back pain with sciatica, and IV drug abuse, was found unresponsive to verbal and painful stimuli. The nursing staff administered Naloxone as ordered by the physician, which aroused the resident, but they exhibited slurred speech and disorientation. The resident was subsequently sent to the hospital, where it was documented that they had an unintentional overdose of oxycodone and baclofen, leading to hypercapnic respiratory failure. Interviews with staff and a review of the clinical record revealed that the resident reported being given too much narcotic medication, resulting in medication poisoning. Despite these events, the facility did not conduct an investigation into the possible neglect or report the incident to the State survey agency. The Nursing Home Administrator and Director of Nursing confirmed the lack of investigation into the case of possible neglect, which constitutes a failure to comply with regulatory requirements.
Failure to Develop Elopement Risk Care Plan
Penalty
Summary
The facility failed to develop a person-centered care plan addressing the risk of elopement for a resident diagnosed with depression, anxiety disorder, borderline personality disorder, and narcissistic personality disorder. The resident was admitted with a physician's order for a wanderguard device to be placed on the wheelchair's armrest to prevent elopement. However, the resident expressed dissatisfaction with the placement of the wanderguard and managed to remove it using a butter knife, indicating a lack of effective intervention to address the resident's elopement risk. The clinical record review and staff interviews revealed that the resident had shown increased aggression and verbal threats to leave the facility, yet the care plan did not reflect these behaviors or include strategies to mitigate the risk of elopement. The Director of Nursing confirmed the absence of a comprehensive care plan tailored to the resident's needs, highlighting a deficiency in the facility's approach to ensuring resident safety and individualized care planning.
Failure to Provide Timely Hearing and Vision Treatments
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident R32, received necessary treatment and assistive devices to maintain hearing and vision abilities. Resident R32, who was cognitively intact and had a history of anxiety disorder, major depressive disorder, rheumatoid arthritis, and osteoporosis, was recommended for myringotomy treatment by an ENT specialist in January 2024. Despite a follow-up ENT consultation in June 2024 and a subsequent hearing assessment in July 2024 indicating decreased hearing, there was no documentation that the resident received the recommended myringotomy treatment. Additionally, a vision consultation in June 2024 recommended cataract surgery for the resident's left eye, but the surgery was delayed. Interviews with the resident and staff revealed that the resident was unable to hear and was concerned about the delay in receiving both hearing and vision treatments. The Director of Nursing confirmed that appointments for the myringotomy and cataract surgery were only scheduled after the surveyor's inquiry in August 2024. The medical records staff, responsible for scheduling appointments, was unaware of the myringotomy recommendation until late August 2024, and a previously scheduled cataract surgery appointment was canceled due to a staffing shortage. The unit manager, responsible for communicating appointment needs, was also unaware of the cancellation and delay in scheduling the myringotomy treatment.
Failure to Implement Effective Elopement Prevention Measures
Penalty
Summary
The facility failed to appropriately determine the effectiveness of interventions for a resident assessed as an elopement risk. The facility's policy required that all residents be evaluated for elopement risk upon admission, re-admission, quarterly, and with any change in status. However, the clinical record for a resident with diagnoses of depression, anxiety disorder, borderline personality disorder, and narcissistic personality disorder did not indicate that an Elopement Risk Evaluation was completed. Despite a physician's order for a wander guard to be placed on the resident's wheelchair, the resident expressed dislike for the device and removed it, indicating the intervention was ineffective. Staff interviews confirmed that the resident's wheelchair did not have a wander guard, and no alternative interventions were explored by the facility. The unit manager confirmed the ineffectiveness of the wander guard intervention and removed the physician order. The Director of Nursing provided a Quarterly Evaluation indicating the resident had attempted to elope in the last 30 days and was at risk for elopement, yet no effective measures were in place to prevent such incidents.
Inadequate Tracheostomy Care and Supply Management
Penalty
Summary
The facility failed to provide appropriate tracheostomy care for a resident, identified as Resident R71, who was admitted with a diagnosis of chronic obstructive pulmonary disease and acute respiratory failure hypoxia. During an observation on August 26, 2024, it was found that the required size 6 trach tube was not available at the resident's bedside or in the medication cart, as per the physician's order. Additionally, a family member reported that the resident's trach collar was left wet after a shower earlier that day, and it was not changed until much later when the assigned nurse returned from a break. Further observations on August 29, 2024, revealed that during a tracheostomy treatment, the licensed nurse performing the procedure did not have a disposable inner cannula readily available, necessitating another nurse to retrieve it from the medication storage room. These deficiencies were confirmed by the Infection Preventionist and the Director of Nursing, indicating lapses in the facility's provision of necessary respiratory care supplies and timely care for the resident.
Failure to Address Pharmacist's Medication Irregularity
Penalty
Summary
The facility failed to ensure that the attending physician addressed and documented the pharmacist's identified irregularities for a resident's medication regimen. The facility's policy requires that any identified irregularity by the pharmacist must be reviewed by the attending physician, who should document the review and any actions taken in the resident's medical record. In the case of Resident R127, who was admitted with multiple diagnoses including depression, dementia with mood disturbance, and difficulty swallowing, the pharmacist noted an irregularity regarding the duration of a PRN psychoactive medication, Trazadone, which was prescribed without a specified duration as required by CMS regulations. Despite the pharmacist's recommendation to update the order for Trazadone to comply with regulations, there was no evidence in Resident R127's clinical record that the attending physician reviewed or documented the need for the continued use of the medication or addressed any potential adverse consequences. This oversight was identified during a review of the resident's clinical record, highlighting a deficiency in the facility's compliance with its own policies and regulatory requirements.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents, leading to deficiencies in infection prevention and control. Resident R4, who had a physician's order for EBP due to MRSA bacteremia and MSSA in a wound, did not have the required red dot on their door sign to alert staff. During wound treatment, a licensed nurse did not use EBP, and the nurse later confirmed the oversight. Similarly, Resident R63, who had a red dot indicating the need for EBP, received wound care without the precautions being followed. The nurse involved was unaware of the requirement for EBP, despite the presence of the red dot. Additionally, Resident R71, who required EBP for tracheostomy treatments, did not receive care with the necessary precautions. A licensed nurse was observed changing the trach collar without using EBP, and the Infection Preventionist confirmed that EBP was required for all tracheostomy treatments. The lack of adherence to EBP protocols for these residents highlights a failure in the facility's infection prevention and control program, as outlined in their policy.
Inaccessibility of Survey Results to Residents and Visitors
Penalty
Summary
The facility failed to ensure that the Department of Health Survey results were readily accessible to residents and visitors across all three nursing units (A, B, C). During a resident group meeting, nine alert and oriented residents reported that they were unaware of the survey results binder and its location. An observation confirmed that the survey binder was placed behind the receptionist desk in the main lobby and behind the nursing station desks on all three units, making it inaccessible to residents. The Nursing Home Administrator, Employee E1, confirmed that the state survey results were not readily accessible for residents, families, and visitors to review.
Failure to Honor Resident's Choice of Healthcare Provider
Penalty
Summary
The facility failed to honor a resident's right to choose their healthcare provider, as evidenced by the case of a resident who explicitly requested not to have a specific licensed nurse, Employee E4, administer his medications. Despite this request, the resident reported that Employee E4 continued to provide care and administer medications on multiple occasions. The resident expressed dissatisfaction with Employee E4's previous medication administration errors and had been assured by facility staff that another nurse, Employee E3, would handle his medication needs. The resident's care plan, which emphasized the importance of allowing the resident to make independent decisions regarding their care, was not adhered to. A review of the Medication Administration Records for March, April, and May 2024 showed that Employee E4 administered medications to the resident on numerous days, totaling 44 instances over the three months. This action was contrary to the resident's expressed wishes and the facility's commitment to uphold resident rights as outlined in their care plan.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,904 citations issued within 25 miles in the last 12 months — including the 27 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Philadelphia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St John Neumann Ctr For Rehab & Healthcare | 0.3 mi | ★★★★★ | 10 | 0 |
| Paul's Run | 0.7 mi | ★★★★★ | 7 | 0 |
| Chapel Manor | 1.6 mi | ★★★★★ | 21 | 0 |
| Delaware Valley Veteran's Home | 2 mi | ★★★★★ | 3 | 0 |
| Accela Rehab And Care Center At Somerton | 2.3 mi | ★★★★★ | 9 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.