Oakwood Healthcare & Rehabilitation Center

Inspectors wroteBased on review of food safety standards, observations, and staff interview it was determined that the facility failed to ensure beverages were stored in accordance with standards for food service safety. Findings Include: Review of Refrigeration & Food Safety guidelines by the United States Department of Agriculture (USDA), Food Safety and Inspection Service, revealed cold food should be kept at or below 40 degrees Fahrenheit (F). Further review of guidelines by the USDA revealed the danger zone is defined as temperatures between 40 and 140 degrees F where bacteria grow most rapidly. A tour of the main kitchen conducted on May 4, 2026, at 9:30 a.m. with the Food Service Director, Employee E11, and District Manager, Employee E12, revealed the following: [...]

Inspectors wroteBased on review of clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for one of two sampled residents (Residents R2).

Inspectors wroteBased on observation and staff interview, the facility failed to ensure medications were stored according to required temperature ranges and failed to maintain refrigeration equipment in a sanitary and operational condition. Findings Included: Review of Medication Room Temperature Log states, temperature are to remain between 36-41 degrees. Defrost freezer monthly on the fifteenth. Observation conducted on May 4, 2026, at 10:30 am, with Nurse Manager, Employee E4 of Medication Room Refrigerator revealed two out of three days the refrigerator temperature exceeded the acceptable range of 36-41 degrees. The facility failed to notify maintenance of the temperature variance and failed to remove or quarantine medications exposed to out of range temperatures. [...]

Inspectors wroteBased on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement Enhanced Barrier Precautions for one of two residents reviewed who had a tracheostomy, feeding tube, and an indwelling urinary Foley catheter (Resident R2).

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility did not ensure that all allegations of abuse and neglect were reported immediately to the Pennsylvania Department of Health for two of 26 residents reviewed. (Resident R24, R433) Findings Include: A review of the facility policy titled Oakwood Health and Rehabilitation Center Policy and Procedure, revised September 2023, revealed the following under Section #6, Investigating and Reporting: Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator of Nursing immediately and initiate gathering the requested information. An investigation must be directed by the Administrator or designee immediately. [...]

Inspectors wroteBased on clinical record review and interview with staff, it was determined that the facility did not ensure that care plans were revised in a timely manner related to fall interventions for one of three records reviewed for falls. (Resident R5).

Inspectors wroteBased on a review of clinical records, and interviews with residents, family members, and staff, it was determined that the facility failed to provide the necessary assistance with activities of daily living (ADLs) to maintain proper grooming for five of the five residents reviewed (Residents R24, R53, R33, R93, R433)

Inspectors wroteBased on review of clinical record reviews and interviews with staff, it was determined that the facility failed to follow the physician orders related to medication administration for one of 26 residents reviewed (Residents R433).

Inspectors wroteBased on review of facility policy, review of clinical records, and interview with staff, it was determined that the facility failed to implement non-pharmacological interventions in accordance with professional standards for one of 26 residents reviewed (Resident R120).

Inspectors wroteBased on review of facility policy and procedures, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices related to the use of appropriate personal protective equipment for one of three nursing units on transmission-based isolation precautions. (B unit)

Inspectors wroteBased on clinical record review, facility policy, and staff interview, it was determined that the facility failed to ensure complete and accurate medication administration for one of 9 residents reviewed (Resident CR1).

Inspectors wroteBased on review of staffing schedules, facility documentation, and staff interview, it was determined that the facility failed to ensure sufficient nursing staff to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being for 3 of 26 residents reviewed (Residents R78, R100, R32).

Inspectors wroteBased on observation, and staff interview, it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of three nursing units (Unit A Medication Cart).

Inspectors wroteBased on review of clinical record, review of policy and procedure, and interviews with staff and residents, it was determined that the facility failed to investigate an allegation of possible abuse and neglect and report to the State survey agency the result of the investigation for one of 26 clinical records reviewed. (Resident R44)

Inspectors wroteBased on clinical record review and staff interviews, it was determined the facility failed to develop person-centered care plans related to elopement for one out of 26 residents sampled (Resident 78).

Inspectors wroteBased on clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive proper treatment and assistive devices to maintain hearing and vision abilities for one of 26 residents reviewed (Resident R32).

Inspectors wroteBased on review of facility policy, facility documentation, review of clinical records, observations, and staff interviews, it was determined that the facility failed to appropriately determine the effectiveness of interventions for a resident who was assessed as an elopement risk for one of the 26 residents reviewed (Resident R78)

Inspectors wroteBased on clinical record review, observations, and staff interviews, it was determined that the facility failed to provide appropriate tracheostomy care for one of 26 residents (Resident R71).

Inspectors wroteBased on review of facility provided documentation, and review of clinical record, it was determined that the facility did not ensure to have attending physician address and document pharmacist's identified irregularities for one of 26 residents reviewed (Resident R127)

Inspectors wroteBased upon review of facility policy and procedure, observation, and clinical record review, it was determined the facility failed to establish Enhanced Barrier Precautions for three of 26 residents observed (Resident 71, Resident 4, and Resident 63)

Inspectors wroteBased on observation and an interview with staff, it was determined that the facility failed to ensure that the Department of Health Survey results were readily accessible to residents and visitors on three of three nursing units. (A, B, C nursing units) Findings Include: On August 27, 2024, at 10:36 a.m. a resident group meeting was held with nine alert and oriented residents ( R75. R115, R83, R83, 51, R55, R34, R4, R99, R48) who reported that they were not aware of the survey results binder and were not aware of the location where the survey results binder would be located and available to review. Observation on August 27, 2024, at 11:27 a.m. revealed the survey binder was in the main lobby behind the receptionist desk. [...]

Inspectors wroteBased on the review of clinical records, interviews with resident and staff, it was determined that the facility failed to ensure that the resident had the right to choose healthcare and providers of healthcare consistent with resident's interests and plan of care for one of three residents reviewed. (Resident R1) Findings Include: Interview with Resident R1 on May 30, 2024, at 10:00 a.m. stated he did not want Employee E4, Licensed Nurse, to provide care for him. He stated after the last survey by the State Survey Agency in September 2023, he did not want her to provide him care and administer medications. Resident also stated she made mistakes with his medication administration, and he was told by the facility staff that Employee E3 would not administer him his medications. [...]