Oxford Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Langhorne, Pennsylvania.
- Location
- 300 East Winchester Ave, Langhorne, Pennsylvania 19047
- CMS Provider Number
- 395710
- Inspections on file
- 31
- Latest survey
- November 14, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Oxford Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Two residents did not receive care according to physician orders: one was given blood pressure medication without required pre-administration BP checks and did not receive as-needed antihypertensive medication when indicated, while another did not have a prescribed compression stocking applied to a swollen leg as ordered. The DON confirmed these lapses in care.
The facility did not maintain a medication error rate below 5%, with two errors observed out of 28 medication administration opportunities. One resident received only half the prescribed dose of Losartan for cardiac conditions, and another received a crushed Protonix delayed release tablet, contrary to administration instructions. The DON confirmed these errors.
A resident was found in a room with small flying insects around her head, ants on the mattress and dresser, large cobwebs by the window, a dried yellow substance on the floor, and a dresser drawer that did not close properly. A family member confirmed ongoing issues with insects, the persistent yellow stain, and the malfunctioning drawer.
The facility failed to maintain accurate and complete medical records for two residents, both diagnosed with muscle wasting and anemia. Despite residents confirming that treatments were administered as ordered, the treatment administration records lacked documentation for specific dates. The Director of Nursing confirmed the documentation failure, leading to a deficiency in compliance with regulations.
The facility failed to implement physician's orders for multiple residents, leading to deficiencies in care. A resident with heart failure and another with dysphagia lacked documented weights as ordered. Two residents with hypertension and heart failure did not have required blood pressure and heart rate checks documented before medication administration. Interviews confirmed the lack of documentation.
The facility failed to develop comprehensive care plans for two residents with dementia, as identified in their assessments. Despite the need to address cognitive decline being noted, there was no evidence of interventions in their care plans. The DON confirmed the lack of documentation for these care areas.
The facility failed to provide adequate grooming and hygiene services for four residents requiring assistance with ADLs. A resident with depression and osteoarthritis had long, dirty nails, while another with adult failure to thrive had long, discolored nails. A third resident with hemiplegia also had long, discolored nails, and a fourth resident with depression had disheveled hair with a large knot. The DON acknowledged that care should have been provided, and there were no documented refusals.
The facility failed to serve meals at scheduled times on the third-floor nursing unit, with meal trays arriving significantly late. Observations showed that several residents received their meals over an hour after the scheduled time, and some residents reported frequent issues with missing trays. Staff confirmed the delays and missing trays, indicating a failure to meet resident needs and preferences.
The facility failed to provide timely written notifications to residents and their representatives regarding hospital transfers, including reasons and Ombudsman information. This deficiency affected three residents who were transferred after a change in condition, with no documentation supporting that the required notifications were given. The Administrator confirmed the lack of notifications.
The facility failed to serve food at acceptable temperatures on the third floor nursing unit. Residents reported that food was often served cold, and a test tray evaluation confirmed that the service temperatures of chicken, potato wedges, and zucchini were below the acceptable range, indicating a failure to meet the facility's standards.
The facility failed to maintain sanitary conditions in the kitchen as two male dietary aides were observed preparing resident lunch trays without wearing beard restraints, violating the facility's policy on preventing foodborne illness. The Food Service Director confirmed the violation.
Failure to Follow Physician Orders for Medication and Treatment
Penalty
Summary
The facility failed to implement physician's orders for two residents, resulting in deficiencies related to medication administration and prescribed treatments. For one resident with hypertension and requiring renal dialysis, staff were ordered to administer metoprolol tartrate twice daily, withholding the medication if the systolic blood pressure (SBP) was less than 110 mmHg. However, documentation showed that the medication was administered 85 times without evidence that blood pressure was assessed prior to administration as required. Additionally, the same resident had an order for hydralazine to be given every eight hours as needed if SBP exceeded 170 mmHg, but there was no evidence that the medication was administered on five occasions when the SBP was above this threshold. Another resident with a history of stroke, diabetes, and muscle wasting had a physician's order for a compression stocking to be applied to the left lower leg in the morning and removed in the evening to address leg swelling. Multiple observations over several days revealed that the resident was seen in the hallway in a wheelchair with visible ankle swelling and without the compression stocking in place. The Director of Nursing confirmed that the compression stocking should have been applied according to the physician's order.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent during medication administration on two of three nursing units. During observed medication passes, there were 28 opportunities for medication administration, with two errors identified, resulting in a 7.14% error rate. One error involved a resident with atrial fibrillation, hypertension, and heart failure, who was prescribed Losartan Potassium 25 mg daily but was only administered 12.5 mg by an LPN, which was half the ordered dose. Another error involved a resident with dementia and gastroesophageal reflux disease, who was prescribed Protonix delayed release tablets, which should not be crushed; however, an LPN crushed the tablet prior to administration. The Director of Nursing confirmed that these medications were not administered according to physician orders.
Failure to Maintain Clean and Safe Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for one resident, as evidenced by direct observation and interview. During an inspection, several small black flying insects were seen around the resident's head and face while she was in bed, and four ants were found on top of the mattress. Additional ants were observed on the dresser, and large cobwebs were present on each side of the window. The floor near the air conditioning unit had a dried yellow substance, and the dresser drawer did not close properly. A family member confirmed that small insects were consistently present in the room, the yellow substance on the floor was permanent, and the dresser drawer was always difficult to close. These findings demonstrate that the facility did not maintain a clean, safe, and homelike environment for the resident, as required by state regulations.
Deficiency in Accurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for two residents, leading to a deficiency in compliance with federal and state regulations. Resident 2, diagnosed with muscle wasting and anemia, had physician's orders to cleanse the sacrum with medihoney and apply skin prep to both heels. However, the treatment administration record (TAR) for February 2025 lacked documentation of these treatments on specific dates, despite the resident confirming that the treatments were applied as ordered. Similarly, Resident 3, also diagnosed with muscle wasting and anemia, had orders to apply skin prep to both heels and a blister on the abdomen. The TAR for February 2025 showed missing documentation for these treatments on several dates, even though the resident confirmed the treatments were administered. The Director of Nursing acknowledged the failure to properly document the treatments, confirming the deficiency in maintaining complete and accurate medical records.
Plan Of Correction
This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report. 1. Resident 2 and 3 Treatments were provided as ordered. 2. An initial audit was completed for residents receiving skin prep to validate residents treatments were documented as administered. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. Licensed nursing staff were educated on the documentation process for treatments. 4. DON/ designee will complete audits 3x per week x4 weeks to validate residents treatments were documented as administered. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
Failure to Implement Physician's Orders for Multiple Residents
Penalty
Summary
The facility failed to implement physician's orders for five residents, leading to deficiencies in care. Resident 24, diagnosed with heart failure and chronic obstructive pulmonary disease, did not have daily weights documented on specified dates as ordered by the physician. Similarly, Resident 34, with dysphagia and chronic obstructive pulmonary disease, lacked documentation for weekly weights on multiple occasions. Resident 145, diagnosed with dependent edema, also had missing documentation for daily weights over several days. Additionally, the facility did not adhere to physician's orders regarding medication administration for Residents 65 and 95. Resident 65, with hypertension, was prescribed lisinopril with a condition to check systolic blood pressure before administration, but there was no documentation of this being done 45 times. Resident 95, with heart failure and diabetes, was prescribed carvedilol with conditions to check both blood pressure and heart rate before administration, yet documentation was missing for 42 instances. Interviews with the Administrator and Director of Nursing confirmed the lack of documentation for these assessments.
Failure to Address Cognitive Decline in Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan to address the cognitive decline and dementia needs of two residents, as identified in their comprehensive assessments. Resident 61, admitted with a diagnosis of dementia, had a Minimum Data Set Care Area Assessment summary dated July 21, 2024, which indicated that cognitive decline/dementia should be addressed in the care plan. However, there was no evidence of interventions for this condition in the current care plan. Similarly, Resident 65, also diagnosed with dementia, had a Care Area Assessment summary dated October 11, 2024, noting the need to address cognitive decline/dementia in the care plan, but no interventions were documented. The Director of Nursing confirmed in an interview on November 15, 2024, that there was no documented evidence that the identified care area was addressed in the care plans of Residents 61 and 65. This deficiency is a violation of 28 Pa. Code 211.12(d)(1)(5) regarding nursing services.
Failure to Provide Adequate Grooming and Hygiene Services
Penalty
Summary
The facility failed to provide adequate grooming and hygiene services for four residents who required assistance with activities of daily living (ADLs). Resident 5, diagnosed with depression, osteoarthritis, and muscle wasting, was observed with long and dirty fingernails, despite expressing a preference for short nails and not refusing care. Resident 27, with diagnoses including adult failure to thrive and muscle wasting, was observed with long and discolored nails on multiple occasions, and her representative confirmed that her nails were not being cut regularly. Resident 81, who has hemiplegia and vertical strabismus, was also observed with long and discolored nails on his right hand, and he stated that staff had not offered to cut them. Additionally, Resident 28, diagnosed with depression and anxiety, was observed with disheveled and unkempt hair, including a large knot at the back of her head. She reported that staff did not offer assistance to wash or comb her hair during bathing. The Director of Nursing acknowledged that nail care should have been provided with bathing and as needed, and that assistance with hair care should have been offered. There were no documented refusals of care for any of these residents.
Delayed Meal Service on Third-Floor Nursing Unit
Penalty
Summary
The facility failed to ensure that meals were served at regularly scheduled times in accordance with resident needs on the third-floor nursing unit. The meal schedule indicated that the second and final meal cart delivery was set for 12:45 p.m. However, observations on November 13, 2024, revealed that the meal cart arrived at 1:10 p.m., and tray pass began at 1:20 p.m., which was 35 minutes after the scheduled time. By 1:28 p.m., the meal cart was empty, yet several residents, including Residents 33, 37, 74, 107, 119, and 139, had not received their meal trays. Further observations showed that meal trays were delivered to Residents 37, 107, 119, and 139 over an hour after the scheduled meal time, while Residents 33 and 74 received their trays over 80 minutes late. Resident 51 had previously stated that meals were often served late, and Resident 37 mentioned that his meal tray was frequently missing. Both Nurse Aide 1 and Licensed Practical Nurse 1 confirmed the delay and the absence of meal trays for some residents. This deficiency was noted under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee.
Failure to Notify Residents of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notifications to residents and their representatives regarding transfers to the hospital, including the reasons for the transfers and Ombudsman information. This deficiency was identified for three residents who were transferred to the hospital after a change in condition. Specifically, Resident 123 was transferred on two occasions, and Residents 139 and 142 were each transferred once. In each case, there was no documentation to support that the residents or their responsible parties were provided with the required written information. The Administrator confirmed in an interview that these notifications were not provided.
Failure to Serve Food at Acceptable Temperatures
Penalty
Summary
The facility failed to provide food that was palatable and at acceptable temperatures on the third floor nursing unit. This deficiency was identified through resident interviews, facility documentation review, observations, and a test tray evaluation. On October 1, 2024, residents reported that food was often served cold. A test tray evaluation conducted on the same day revealed that the service temperatures of the chicken, potato wedges, and zucchini were below the acceptable range of 115 to 135 degrees Fahrenheit, with temperatures recorded at 114.5, 113.5, and 119.1 degrees Fahrenheit, respectively. These food items were noted to be cool to taste, indicating a failure to meet the facility's standards for food temperature.
Failure to Maintain Sanitary Conditions in the Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen. During a tour of the kitchen, two male dietary aides were observed assisting on the tray line preparing resident lunch trays without wearing beard restraints, which is a violation of the facility's policy on preventing foodborne illness. The policy, dated April 3, 2024, requires beard restraints to be worn when cooking, preparing, or assembling food to prevent hair from contacting exposed food, clean equipment, utensils, and linens. The Food Service Director confirmed that the dietary aides should have had beard restraints in place as per the facility policy.
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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