Oak Glen Healthcare And Rehabilitation Center

Based on staff interviews it was determined that the facility failed to have sufficient competent dietary staff to perform essential kitchen duties (Employee 2).Findings include:Observation and interview with Employee 2, dietary aide, on August 19, 2025, at 9:30 AM revealed the employee was washing breakfast dishes and flatware in the dish room area of the main kitchen with an industrial dish washing machine. Upon request of the dish machine temperature log (documentation of machine wash and rinse temperatures to ensure proper sanitization), Employee 2 indicated she was not aware of the temperature log. Employee 2 indicated she had worked at the facility as a dietary aide for one month and was working independently as she had served food on one of the nursing units, washed some items in a dishwasher on the unit, and then came to the main kitchen to wash additional items. Employee 2 then stated another employee who works as a dish washer comes in later in the morning, but she was responsible to get the breakfast dishes/utensils washed before the dish washer comes in. Employee 2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility failed to maintain clinical records that were complete and accurate for three of 20 residents reviewed (Residents 4, 82, and 105). Findings include: Clinical record review for Resident 4 revealed a care plan that noted the resident has a potential alteration in nutritional status related to the medical history. An intervention included to provide and serve diet and supplements as ordered and monitor intake and record every meal. Further review of Resident 4's care plan revealed the resident has a pressure ulcer and an intervention included to monitor nutritional status. The care plan instructed staff to serve the diet as ordered and monitor intake and record. A review of Resident 4's meal intakes for the last 30 days revealed the following days were not recorded as directed in the resident's care plan:July 26, 2025August 5, 2025August 9, 2025August 15, 2025August 18, 2025 Clinical record review for Resident 82 revealed a care plan that noted the resident has a potential alteration in nutritional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policies, clinical record review, and staff interview it was determined that the facility failed to administer a pneumococcal vaccine to a resident who consented to and was eligible to receive it for one of five residents selected for vaccination review (Resident 53).Findings include: The facility policy entitled, Infection Control - Vaccination Policy, last reviewed January 16, 2025, revealed that the purpose of the policy is to prevent infection and control the potential spread of COVID-19, influenza, and pneumococcal pneumonia through adherence to Centers for Disease Control and Prevention (CDC) vaccination guidelines and recommendations. Each resident is offered immunization unless it is medically contraindicated, or the resident has already received the vaccine. Refer to the CDC guidelines for vaccine type and timing: CDC Pneumococcal Vaccine Timing. CDC Pneumococcal Vaccine Timing for Adults (https://www-new.cdc.gov/pneumococcal/downloads/Vaccine-Timing-Adults-JobAid.pdf)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, and staff and family interview, it was determined that the facility failed to provide adequate maintenance services to maintain an orderly environment in a main hallway of the facility (Resident 29). Findings include: Interview with Resident 29's family on September 24, 2024, at 11:20 AM revealed that the facility has had a leaking roof in the hallway for a while now. Observation of a hallway located near the facility's beauty shop on September 26, 2024, at 10:12 AM revealed that the roof was leaking through the ceiling tiles onto the carpeted area. The hallway connects nursing units and provides residents with access to services such as the beauty salon, human resources, therapy, and administration. The facility had two large trash cans placed under the leak attempting to catch the dripping water. There were two large ceiling tiles that were saturated with water with holes in them that were dripping water into the trash cans and surrounding carpet. There was a six-foot area of wet carpet surrounding the trash cans. There was a musty wet odor that was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policies and procedures, clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide the highest practicable care regarding cardiac pacemakers and central venous catheters for three of 19 residents reviewed (Residents 27, 61, and 82). Findings include: Clinical record review for Resident 27 revealed nursing documentation dated September 9, 2024, at 7:45 PM that Resident 27, .returned to facility. Report from hospital staff that line was kinked, and they were able adjust it. It is now patent. Active physician orders for Resident 27 included instructions to change a PICC line (Peripherally Inserted Central Catheter, thin, soft, flexible tube inserted through a vein in the arm and passed through to the larger veins near the heart for the administration of fluids or medication) intravenous dressing every Wednesday. The orders also included instructions to instill heparin (an anticoagulant medication that prevents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, it was determined that the facility failed to store food items and maintain equipment in a sanitary manner in the facility's main kitchen. Findings included: Initial tour of the facility's main kitchen with Employee 5, General Dietary Manager, on September 24, 2024, between 9:15 AM and 9:40 AM revealed the following: A large circulating fan in the dishwashing area had a significant build-up of dust on the protective guards. The dry storage room contained an open container of peanut butter with no open date on it. A walk-in freezer had a package of croissants that were open and uncovered, exposing several of them to the ambient air. A walk-in cooler had the following findings: a head of celery on a shelf that was not covered exposing it to ambient air; five unused packages of butter in a cardboard box that were partially open and another partially used package of butter that was open and not dated; an open package of mixed vegetables that had a build-up of moisture on the package and no open date on it; two large onions and one partially used…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to establish clear and consistent resident wishes regarding advance directives for one of five residents reviewed (Resident 66). Findings include: Clinical record review for Resident 66 revealed a current physician's order initiated on [DATE], that indicated her code status (the type of emergency care to be initiated if the resident's heart stops or they stop breathing) to be DNR (Do not resuscitate). Further clinical record review revealed a facility form entitled, Decision of Agent, Guardian, or Health Care Representative Cardiopulmonary Resuscitation (CPR, an emergency procedure that combines chest compressions and rescue breathing when a person's heartbeat or breathing has stopped) Status of Incompetent Resident that indicated the Resident's health care agent did not wish to decide at this time regarding the resident's CPR status. The form was signed and dated [DATE]. The Director of Nursing and Nursing Home…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility failed to provide care or services to maintain a resident's ambulation status for one of two residents reviewed for ambulation concerns (Resident 17). Findings include: Clinical record review for Resident 17 revealed a Restorative Program Note dated September 5, 2024, at 1:30 PM that indicated she would start a new restorative program for ambulation. The program details include for her to be ambulated with a front wheeled walker in straight paths with the assistance of one staff with one staff to follow with a wheelchair. Review of the task documentation (electronic documentation of care provided) for the dates of September 5-25, 2024, revealed a task for Restorative ambulation to be completed every shift. Interview with Employee 6 (Assistant Director of Nursing) on September 26, 2024, at 2:00 PM revealed that the expectation was for the task to be completed once a day. She said it was scheduled every shift so that if one shift did not get the task done, the next shift could do it. Further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, clinical record review, and staff interview, it was determined that the facility failed to appropriately use a positional device related to contractures for one of two residents reviewed (Resident 80). Findings include: Observation of Resident 80 on September 25, 2024, at 9:20 AM revealed she was sitting in the dining room with a travel neck pillow positioned behind her neck. Resident 80's neck naturally is contracted forward and to her left. The bulk of the travel pillow was positioned with the middle directly on the back of her neck, essentially pushing her neck further forward. Review of Resident 80's clinical record revealed an admission Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated July 10, 2024, that indicated the facility assessed Resident 80 as having range of motion limitations to one side of both her upper and lower extremities. There was no documented evidence to indicate the use of a travel neck pillow in Resident 80's clinical record until after this surveyor's observations.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a complete medical record was accessible to the survey team timely for one of six residents reviewed (Residents 10). Findings include: The surveyor reviewed the requirement for resident electronic health records (surveyor access to any information that should be a part of the resident's medical record) during an entrance conference interview with the Nursing Home Administrator and Director of Nursing on September 24, 2024, at 8:53 AM. Clinical record review for Resident 10 on September 24, 2024, at 11:19 AM (first day of the onsite survey) with the Nursing Home Administrator and Employee 6 (assistant director of nursing) revealed that the surveyors' access to the electronic medical record did not permit the review of all physician orders available for Resident 10. The physician orders available did not include any medications or advance care planning decisions for Resident 10. Interview with the Nursing Home Administrator on September 24, 2024, at 12:15 PM indicated that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview it was determined that the facility failed to offer the COVID-19 vaccine to one of five residents reviewed for immunizations (Resident 59). Findings include: Current CDC guidelines at https://www.cdc.gov/covid/vaccines/stay-up-to-date.html recommend that everyone ages six months and older should get a 2024-2025 COVID-19 vaccine. Vaccine protection decreases over time, so it is important to stay up to date with your COVID-19 vaccine. This includes people who have received a COVID-19 vaccine before and people who have had COVID-19. Interview with Employee 7 (registered nurse/infection control prevention coordinator) on September 26, 2024, at 8:47 AM indicated that any information regarding a resident's vaccination history is contained in the electronic medical record under the immunization section. Employee 7 stated, that's what I go by. Clinical record review for Resident 59 revealed that the facility admitted him on August 19, 2022, and his most recent COVID-19 booster was administered on February 14, 2023. Resident 59's medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered medications for one of 19 residents reviewed (Resident 70). Findings include: Clinical record review for Resident 70 revealed a current physician's order dated March 2, 2023, for staff to administer Oxybutynin Chloride (for incontinence) 2.5 milligrams (mg) every day by mouth for one week (March 9, 2023) then stop. Observation of a medication administration pass on October 24, 2023, at 9:00 AM with Employee 7, licensed practical nurse, revealed that she administered Oxybutynin 2.5 mg by mouth to Resident 70. Review of Resident 70's clinical documentation revealed that staff continued to administer Resident 70's Oxybutynin until after the surveyor identified the concern on October 26. 2023. The surveyor reviewed the above information during an interview on October 26, 2023, at 10:00 AM with the Nursing Home Administrator. 483.25 Quality of Care Previously cited 10/21/22 28 Pa. Code 211.10(c) Resident care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner in the facility's main kitchen and on one of six nursing units (Evergreen Nursing Unit). Findings include: A tour of the facility's main kitchen with Employee 4 (Kitchen Operations Manager) and Employee 5 (General Manager) on October 24, 2023, at 9:03 AM revealed the following concerns: The ceiling in the dishwashing area had a section of chipped and missing paint. A concurrent interview with Employee 4 revealed it was unclear what had damaged the ceiling. There was an accumulation of debris on the floor under the stainless steel shelves adjacent to the dishwasher against the wall. An outside entrance leading to the dumpsters had a barrel full of grease positioned on a pallet adjacent to a storm drain. There was a large accumulation of dead leaves under the pallet. The lid was partially ajar, and grease was visible at the lip of the barrel. Employee 5 reported the grease was from the facility fryers and it was unclear how long it had been there. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of select facility policy and procedures, observation, and staff and resident interview, it was determined that the facility failed to determine a resident's capability to self-administer their medications for one of 19 residents reviewed (Resident 12). Findings include: Review of the policy titled, Self-Administration of Medications, revealed that residents have a right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Observation of Resident 12 on October 24, 2023, at 11:32 AM revealed the resident had Biofreeze Gel (a medication used to relieve minor aches and pain) and Fluticasone nasal spray (a medication used to treat certain nasal conditions and seasonal allergies) on the bedside table. A concurrent interview revealed Resident 12 used the gel for aches and the nasal spray for a clogged nose. Current physician orders for Resident 12 revealed an order for fluticasone propionate 50 microgram (mcg) / actuation nasal spray suspension as needed; administer two sprays each…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of select facility policies, clinical record review, and staff interview, it was determined that the facility failed to develop and implement an abuse prohibition policy to ensure a complete and thorough investigation of an incident involving the potential for abuse for one of 19 residents reviewed (Resident 60). Findings include: The policy entitled Resident Rights - Abuse and Crimes against last reviewed without changes on September 21, 2023, revealed that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The administrator or designee is responsible for initiating an investigation as soon as reasonably practicable and completing the investigation in a timely manner. Results of all investigations of alleged violations must be reported within five working days of the incident. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source, the administrator/designee is responsible for determining what actions (if any) are needed for the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for one of 19 residents reviewed (Residents 87). Findings include: Review of Resident 87's clinical record revealed a Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated October 2, 2023, indicating that the facility assessed her as being discharged to the hospital. A nursing progress noted dated September 21, 2023, at 7:55 AM indicated that Resident 87 was discharged from the facility with home health services. Interview with the Administrator and Director of Nursing on October 26, 2023, at 2:01 PM confirmed that Resident 87's MDS was coded in error for discharge status. 483.20(g) Accuracy of Assessments Previously cited 10/21/22 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review, and resident, responsible party, and staff interview, it was determined that the facility failed to provide a dependent resident assistance with nail care for one of one resident reviewed for activities of daily living (Resident 11). Findings include: A phone interview with the responsible party for Resident 11 on October 25, 2023, at 10:41 AM revealed concerns related to the resident's fingernail care and reported the nails were long with dirt under them. The responsible party reported speaking to several people several times about the concerns, but the concerns were not corrected. Observation of Resident 11's fingernails on October 25, 2023, at 11:12 AM with Employee 8, nurse aide, revealed the resident's nails were long with obvious black colored debris noted under the right thumb and pointer finger. The resident voiced, They look terrible. A concurrent interview with Employee 8 revealed the fingernails may be long because the resident is a diabetic and staff would have to check with the nurse prior to trimming. Clinical documentation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility failed to provide physician ordered services to maintain a resident's range of motion for one of four residents reviewed (Residents 19). Findings include: Clinical record review for Resident 19 revealed a current 's order for staff to provide restorative continuous AROM (active range of motion, movement of the body in an attempt to maintain a resident's ability) with assistance as needed (PRN) to her bilateral (BL) shoulders, elbows, and wrists for two sets of 10 repetitions each and restorative continuous PROM (passive range of motion) to her BL knees and ankles for three sets of 10 repetitions each. Review of task documentation for Resident 19 for August, September, and October 2023, revealed that staff did not document completion of the restorative task on the following dates: AROM BL Shoulders, Elbows, and Wrists August 29, 2023 September 4, 6, 16, and 29, 2023 October 17, 2023 PROM BL Knees and Ankles- August 29, 2023 September 6, 16, and 29, 2023 October 17, 2023 The surveyor reviewed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to prevent falls and/or injuries for one of seven residents reviewed (Resident 60). Findings include: Clinical record review for Resident 60 revealed a current physician's order for staff to check the (motion) alarm to ensure that it is intact to the door to decrease intrusions in the room by other residents. Observation of Resident 60 on the following dates and times revealed that the motion alarm did not sound upon entry to her room: October 24, 2023, at 9:47 AM and 10:02 AM October 25, 2023, at 10:45 AM October 26, 2023, at 10:21 AM Concurrent interview on October 26, 2023, at 10:21 AM with the Director of Nursing (DON) confirmed that Resident 60's motion alarm did not sound upon entry to her room. The DON replaced Resident 60's alarm. 483.25(d)(1)(2) Free Of Accident Hazards/supervision/devices Previously cited 10/21/22 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide appropriate treatment and services regarding bladder incontinence for one of two residents reviewed (Resident 4). Findings include: The policy entitled Urinary Incontinence-Clinical Protocol, last reviewed on September 21, 2023, indicates that the facility's physician will look for findings related to continence, categorize the incontinence as urge, stress, overflow, or functional, and will address the treatable causes of urinary retention and incontinence. The policy further indicates that nursing staff will identify, and document circumstances related to the incontinence, and based on assessment of the category and causes of incontinence, will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status. Review of Resident 4's clinical record revealed a Minimum Data Set Assessment (MDS, an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.