Oakwood Healthcare & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 2109 Red Lion Road, Philadelphia, Pennsylvania 19115
- CMS Provider Number
- 395110
- Inspections on file
- 23
- Latest survey
- June 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Oakwood Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
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.
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.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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