Inspection Reports for
Oakwood Residence
2109 Red Lion Rd, Philadelphia, PA 19115, USA, PA, 19115
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
10.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
130% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
42% occupied
Based on a January 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jun 5, 2025
Visit Reason
The inspection was conducted based on complaints alleging neglect, failure to report abuse, inadequate care planning, failure to follow physician orders, improper pain management, and infection control issues at Oakwood Healthcare & Rehabilitation Center.
Complaint Details
The investigation was complaint-driven, focusing on allegations of neglect, failure to report abuse, inadequate care planning, medication errors, pain management deficiencies, and infection control breaches. The complaints were substantiated as the facility was found deficient in multiple areas.
Findings
The facility failed to timely report allegations of abuse and neglect, did not revise care plans promptly after falls, failed to provide adequate assistance with activities of daily living for multiple residents, did not follow physician orders for medication administration, failed to implement non-pharmacological pain management interventions, and did not adhere to infection control protocols related to PPE use on a nursing unit.
Deficiencies (6)
F 0609: The facility failed to timely report suspected abuse and neglect to the Pennsylvania Department of Health for two residents.
F 0657: The facility did not ensure care plans were revised timely related to fall interventions for one resident after an unwitnessed fall resulting in fracture.
F 0677: The facility failed to provide necessary assistance with activities of daily living to maintain proper grooming for five residents.
F 0684: The facility failed to follow physician orders related to medication administration for one resident, delaying sliding scale insulin orders.
F 0697: The facility failed to implement non-pharmacological pain management interventions for one resident requiring such services.
F 0880: The facility failed to follow infection control practices related to appropriate PPE use for residents on transmission-based isolation precautions on one nursing unit.
Report Facts
Residents reviewed: 26
Doses of oxycodone administered: 39
Doses of oxycodone administered: 3
Residents in resident council meeting: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E2 | Director of Nursing | Named in failure to report abuse and neglect, failure to follow medication orders, and pain management deficiencies |
| Employee E6 | Charge Nurse | Named in failure to report neglect allegations and infection control issues |
| Employee E5 | Unit Manager | Named in failure to report neglect and infection control issues |
| Employee E4 | Licensed Nurse | Confirmed grooming deficiencies and infection control observations |
| Employee E3 | Physician | Reviewed and verified medication orders for Resident R433 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 5, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report allegations of abuse and neglect, inadequate assistance with activities of daily living, and failure to follow physician medication orders for residents.
Complaint Details
The investigation was complaint-driven, focusing on allegations of neglect and failure to report abuse for residents R24 and R433. The allegations were substantiated as the facility failed to report and respond appropriately to these concerns.
Findings
The facility failed to report allegations of abuse and neglect immediately to the Pennsylvania Department of Health for two residents. The facility also failed to provide necessary assistance with activities of daily living, including toileting hygiene and grooming, for five residents. Additionally, the facility did not follow physician orders related to sliding scale insulin administration for one resident.
Deficiencies (3)
F 0609: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. The facility failed to ensure all allegations of abuse and neglect were reported immediately for two residents.
F 0677: Provide care and assistance to perform activities of daily living for any resident who is unable. The facility failed to provide necessary assistance with ADLs to maintain proper grooming for five residents.
F 0684: Provide appropriate treatment and care according to orders, resident’s preferences and goals. The facility failed to follow physician orders related to medication administration for one resident, delaying sliding scale insulin order implementation.
Report Facts
Residents reviewed: 26
Residents affected by ADL deficiencies: 5
Residents affected by abuse/neglect reporting deficiencies: 2
Residents affected by medication administration deficiency: 1
Resident council meeting attendees: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E6 | Charge Nurse | Failed to report allegation of neglect to Director of Nursing; aware of reporting requirements but did not report due to surveyors on-site. |
| Employee E2 | Director of Nursing | Was not initially aware of neglect allegations; confirmed failure to follow sliding scale insulin orders. |
| Employee E5 | Unit Manager | Apologized for neglect concerns; confirmed medication administration record issues. |
| Employee E4 | Licensed Nurse | Confirmed observations of residents' grooming deficiencies; aware of neglect situation involving Resident R433. |
| Employee E3 | Physician | Verified medication orders for Resident R433. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 10, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding incomplete and inaccurate medication administration for one resident at Oakwood Healthcare & Rehabilitation Center.
Complaint Details
The complaint investigation found that the facility failed to ensure complete and accurate medication administration documentation for one of nine residents reviewed. The deficiency was substantiated with interviews and record reviews.
Findings
The facility failed to ensure complete and accurate documentation of medication administration for one of nine residents reviewed. Specifically, a licensed nurse administered Acetaminophen but did not document it in the medication administration record.
Deficiencies (1)
28 Pa. Code 211.12(d)(1) Nursing services: The facility failed to document the complete and accurate administration of Acetaminophen for one resident as required by policy and regulation.
Report Facts
Residents reviewed: 9
Days of Levaquin treatment: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E6 | Licensed Nurse | Named in medication administration documentation deficiency |
| Employee E7 | Medical Physician | Ordered chest X-ray and Levaquin treatment |
| Employee E2 | Director of Nursing | Confirmed the documentation deficiency by licensed nurse Employee E6 |
Inspection Report
Monitoring
Census: 37
Capacity: 89
Deficiencies: 5
Date: Jan 28, 2025
Visit Reason
The visit was a partial, unannounced monitoring inspection conducted to review the facility's compliance with regulatory requirements and verify the implementation of a previously submitted plan of correction.
Findings
The inspection identified several deficiencies related to food storage, medication storage, medication availability, and documentation of blood glucose monitoring. The facility submitted plans of correction which were accepted and later determined to be fully implemented.
Deficiencies (5)
Boxes of food were stored on the floor in the main kitchen.
Expired medication was still in the medication cart beyond the manufacturer’s recommended discard date.
Resident's glucometer was not calibrated for the correct date and time, and blood glucose readings were documented in incorrect time slots.
Medication prescribed for general discomfort was not available in the home.
Medications prescribed to residents, including patches and blood glucose monitoring, were not available or properly documented as required.
Report Facts
Total Daily Staff: 42
Waking Staff: 32
Residents Served: 37
License Capacity: 89
Current Residents in Hospice: 2
Residents Age 60 or Older: 36
Residents with Mobility Need: 5
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in multiple findings related to medication reordering, staff education, audits, and compliance monitoring. |
Inspection Report
Routine
Deficiencies: 10
Date: Aug 29, 2024
Visit Reason
Routine state survey inspection of Oakwood Healthcare & Rehabilitation Center to assess compliance with healthcare regulations and resident care standards.
Findings
The facility was found deficient in multiple areas including failure to make survey results accessible to residents, maintain confidentiality of medical records, investigate abuse allegations, develop comprehensive care plans, provide timely vision and hearing services, ensure effective elopement interventions, provide appropriate respiratory care, maintain adequate staffing levels, address pharmacist medication irregularities, and implement infection prevention protocols.
Deficiencies (10)
F 0577: Facility failed to ensure Department of Health Survey results were readily accessible to residents and visitors on three nursing units.
F 0583: Facility failed to maintain confidentiality of residents' medical information on one nursing unit due to unattended medication carts with open computer screens.
F 0610: Facility failed to investigate an allegation of possible abuse and neglect and report the results for one resident with an unintentional medication overdose.
F 0656: Facility failed to develop person-centered care plans related to elopement risk for one resident who removed a wander guard device.
F 0685: Facility failed to ensure residents received proper treatment and assistive devices for hearing and vision, delaying recommended myringotomy and cataract surgeries.
F 0689: Facility failed to determine effectiveness of elopement interventions for one resident, with no elopement risk evaluation completed and ineffective wander guard use.
F 0695: Facility failed to provide appropriate tracheostomy care, lacking required supplies at bedside and not following infection control precautions.
F 0725: Facility failed to ensure sufficient nursing staff to meet residents' needs, resulting in delayed care and inadequate supervision.
F 0756: Facility failed to ensure attending physician addressed pharmacist-identified medication irregularities for one resident on trazadone.
F 0880: Facility failed to implement infection prevention program by not using Enhanced Barrier Precautions during wound and tracheostomy care for multiple residents.
Report Facts
Residents reviewed: 26
Resident group meeting participants: 9
Staffing: 3
Staffing: 2
Medication order duration: 14
Scheduled appointments: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E1 | Nursing Home Administrator | Confirmed survey results not accessible and failure to investigate abuse allegation |
| Employee E3 | Infection Preventionist | Observed tracheostomy care deficiencies and confirmed Enhanced Barrier Precautions requirements |
| Employee E4 | Licensed Nurse | Confirmed Resident R78 wheelchair had no wander guard and staffing shortages |
| Employee E5 | Licensed Nurse | Assigned medication cart left unattended, failed to use Enhanced Barrier Precautions, and delayed trach collar change |
| Employee E11 | Medical Record Staff | Scheduled appointments and retrained on Enhanced Barrier Precautions |
| Employee E12 | Licensed Nurse | Observed performing tracheostomy care without disposable inner cannula at bedside |
| Employee E13 | Licensed Nurse | Confirmed wander guard removal and ineffectiveness for Resident R78 |
| Employee E15 | Licensed Nurse / Unit Manager | Confirmed staffing shortages, ineffective elopement interventions, and call bell not working |
| Employee E16 | Licensed Nurse | Documented Resident R78's refusal of meds and aggressive behavior |
| Employee E25 | Regional RN / Nursing Aide | Confirmed staffing shortages and delayed resident care |
| Employee E9 | Pharmacist | Identified medication order irregularities for Resident R127 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 30, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to honor a resident's right to choose healthcare providers, specifically concerning medication administration by a licensed nurse.
Complaint Details
The complaint was substantiated. Resident R1 reported that Employee E4 administered medications despite his request not to have her provide care. The Unit Manager confirmed that Employee E4 should not administer medications to Resident R1, but records showed Employee E4 administered medications on multiple days in March, April, and May 2024.
Findings
The facility failed to ensure that Resident R1's right to choose healthcare providers was respected, as Licensed Nurse Employee E4 administered medications to the resident multiple times despite the resident's explicit request not to have her provide care.
Deficiencies (1)
28 Pa. Code 201.29 (a) Resident rights and 28 Pa. Code 201.18 (b)(2) Management. The facility failed to honor Resident R1's right to choose healthcare providers by allowing Licensed Nurse Employee E4 to administer medications despite the resident's request not to have her provide care.
Report Facts
Medication administration days by Employee E4: 17
Medication administration days by Employee E4: 9
Medication administration days by Employee E4: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E4 | Licensed Nurse | Named in medication administration violation involving Resident R1 |
| Employee E3 | Unit Manager | Confirmed Employee E4 should not administer medications to Resident R1 |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Nov 9, 2023
Visit Reason
The inspection was conducted following a complaint investigation related to resident care concerns, including mental abuse allegations, failure to accommodate resident preferences, and medication administration issues.
Complaint Details
The complaint involved mental abuse allegations by Resident R48 against two nurse aides who were observed whistling and triggering the resident. The facility investigated and found one nurse aide denied the behavior, while the other did not provide a statement. The resident also reported prior incidents. Additional complaints included inadequate personal care, medication administration errors, infection control breaches, menu deficiencies, and equipment maintenance issues.
Findings
The facility was found to have multiple deficiencies including failure to accommodate resident preferences, inadequate personal care, improper administration of blood pressure medication outside physician orders, failure to follow infection control protocols, inadequate menu planning, and unsafe food service equipment maintenance.
Deficiencies (6)
F 0558: Facility failed to accommodate resident preferences to promote a homelike environment for one resident, including issues related to mental abuse allegations involving staff whistling.
F 0676: Facility failed to provide proper nail care, dressing, and bathing for one resident, resulting in disheveled appearance and unmet grooming needs.
F 0684: Facility did not provide needed care and services according to orders and professional standards related to administering blood pressure medication outside physician ordered parameters for two residents.
F 0803: Menus were not followed as planned, updated, or reviewed by the dietitian, failing to meet nutritional needs and preferences of residents on three nursing units.
F 0880: Facility failed to maintain an effective infection control program; a nurse aide did not follow Enhanced Barrier Precautions for a resident on isolation.
F 0908: Facility did not keep all essential food service equipment working safely; walk-in refrigerator door was broken and temperatures were above safe levels.
Report Facts
Days reviewed for bathing: 14
Medication doses administered outside parameters: 10
Temperature readings: 50
Temperature readings: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E14 | Nurse Aide | Accused of mental abuse by Resident R48 and observed whistling on unit A. |
| Employee E15 | Nurse Aide | Accused of mental abuse by Resident R48; denied whistling and not assigned to care for Resident R48. |
| Employee E16 | Licensed Nurse | Confirmed findings related to Resident R4's grooming; administered blood pressure medication outside parameters; completed medication error in-service. |
| Employee E17 | Licensed Nurse | Administered blood pressure medication outside parameters for Resident R48. |
| Employee E18 | Licensed Nurse | Administered blood pressure medication outside parameters for Resident R48. |
| Employee E4 | Director of Dietary Services | Observed meal tray evaluation and confirmed menu deficiencies. |
| Employee E5 | Dietitian | Confirmed menus were not reviewed, signed, or approved for nutritional adequacy. |
| Employee E12 | Nurse Aide | Failed to follow Enhanced Barrier Precautions for Resident R99. |
| Employee E10 | Unit Manager, Licensed Nurse | Confirmed Resident R99 was on Enhanced Barrier Precautions. |
| Employee E7 | Maintenance Director | Reported walk-in refrigerator door broken since August 2023. |
Inspection Report
Renewal
Census: 29
Capacity: 89
Deficiencies: 12
Date: Sep 27, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection found multiple deficiencies related to medication security, bathroom ventilation, lighting, food storage, refrigerator temperatures, unobstructed egress, combustible storage, fire drill scheduling, medication labeling, medication availability, and medication record keeping. All deficiencies had plans of correction accepted and were implemented by 12/11/2023.
Deficiencies (12)
Medication room was left unlocked, unattended, and accessible to staff.
Bathroom 316 does not have an operable ventilation fan and no window.
Resident in room did not have access to a source of light that can be turned on/off at bedside.
Emergency food was stored on the floor in the medication room closet.
Refrigerator temperature in the 2nd floor dining room was 44 degrees Fahrenheit, above required 40°F.
Hospital bed blocked the egress door next to the activity room.
One gallon of paint and a piece of drywall were stored near the heating source.
Fire drills routinely held during last three days of the month; September drill not conducted as of inspection date.
Medication room and medication cart were unlocked and unattended; creams and lotions stored in unlocked side bin of medication cart.
Pharmacy label for resident medication was torn and did not include full directives.
Resident prescribed medication as needed was not available in the home.
Resident medication administration record did not indicate the date of discontinuation for a medication.
Report Facts
License Capacity: 89
Residents Served: 29
Total Daily Staff: 31
Waking Staff: 23
Fire Drills Dates: 7
Refrigerator Temperature: 44
Inspection Report
Renewal
Census: 35
Capacity: 89
Deficiencies: 8
Date: Jul 27, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection identified multiple deficiencies including sanitary conditions, missing first aid kit items, improper refrigerator/freezer temperatures, lint accumulation in dryer, lack of posted activity calendar, and incomplete resident assessments and support plans. All deficiencies had plans of correction accepted and were documented as implemented.
Deficiencies (8)
Bathroom had a strong urine smell and sticky floor.
First aid kit in the nursing office did not include scissors.
Kitchenette refrigerator temperature was 41°F and ice cream freezer was 5°F, exceeding required temperatures.
Approximately 1/2 inch accumulation of lint in the lint trap of the dryer in the third floor laundry room.
No current weekly activity calendar posted in a public and conspicuous place in the home.
Resident #1's assessment did not include an assessment for personal hygiene.
Resident #2's assessment did not include assessments for managing finances, making and keeping appointments, and long term memory.
Resident #3's support plan did not document how needs for managing healthcare, securing healthcare, doing laundry, shopping, securing and using transportation, managing finances, and making or keeping appointments will be met.
Report Facts
License Capacity: 89
Residents Served: 35
Temperature: 41
Temperature: 5
Lint Accumulation: 0.5
Staffing: 38
Waking Staff: 29
Residents with Mobility Need: 3
Residents 60 Years or Older: 35
Hospice Residents: 1
Notice
Capacity: 89
Deficiencies: 0
Date: Jun 10, 2021
Visit Reason
This document serves as a renewal notification and issuance of a regular license for Oakwood Residence, a Personal Care Home, following receipt of the renewal application. It also advises that an annual onsite inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms the issuance of a license and outlines the requirement for a future annual inspection to ensure compliance.
Report Facts
Maximum capacity: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report
Renewal
Census: 32
Capacity: 89
Deficiencies: 2
Date: Apr 22, 2021
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing requirements on 04/22/2021 and 04/23/2021.
Findings
The submitted plan of correction was determined to be fully implemented. Two deficiencies were identified: one related to a resident-home contract not signed by the administrator or designee, and another related to incomplete medication administration training records for a staff person.
Deficiencies (2)
The resident-home contract for resident 1 was not signed by the Administrator or the Designee.
The home's medication administration training record for staff person A does not include a successful completion of the annual practicum for medication administration training.
Report Facts
License Capacity: 89
Residents Served: 32
Current Residents in Hospice: 1
Residents Age 60 or Older: 32
Residents with Mobility Need: 2
Total Daily Staff: 34
Waking Staff: 26
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