F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on clinical record review, review of facility policy and interviews with residents and staff, it was
determined that the facility did not ensure that physician's orders were obtained regarding oxygen therapy
for one resident out of 26 residents reviewed. (Resident R45)
Residents Affected - Few
Findings include:
Review of facility policy, Respiratory Care and Oxygen Equipment, dated January 29, 2024, states, Oxygen
therapy will be administered per provider's order according to standards of practice.
Observations during the initial tour of Unit A on December 9, 2024, at 11:35 a.m. revealed Resident R45, in
bed wearing a nasal cannula (a device that delivers extra oxygen through a tube and into your nose)
connected to an oxygen concentrator (a medical device that pulls air from the room, separates and
compresses oxygen from the air, while also removing nitrogen) running at 4 liters per minute. Interview with
Resident R45 revealed that she had been on the oxygen since her recent hospitalization.
Further observation of Resident R45 on December 10, 2024, at 9:21 a.m. and again on December 11,
2024, at 11:33 a.m. revealed that she was wearing the nasal cannula receiving oxygen at 4 liters per
minute.
Review of Resident R45's medical record revealed no physician's order for oxygen therapy.
Interview with the Director of Nursing, DON, on December 11, 2024, at 12:56 p.m. confirmed that Resident
R45 had returned from an emergency room visit on 4 liters of oxygen continuously that she was able to find
on her hospital discharge summary. The DON confirmed that the nurse had not put the order in for the
physician for the continuous oxygen therapy at 4 liters per minute for Resident R45.
28 Pa. Code:201.18(b)(1)(3) Management.
28 Pa. Code:211.12(d)(1)(5) Nursing services.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
395370
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395370
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Luther Woods Nursing and Rehabilitation Center
313 County Line Road
Hatboro, PA 19040
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to
ensure that controlled drugs subject to abuse are stored and labeled in accordance with professional
standards for one of two medication rooms observed (B wing medication room).
Findings include:
Review of Facility Policy on Policy: medication and biologicals are stored safely, securely, and properly,
following manufacturer's recommendation or those of the supplier. The medication supply is accessible to
licensed nursing personnel pharmacy personnel or staff members lawfully authorized to administer
medications.
Observation of the B wing Medication Storage room conducted on December 9, 2024, at 11:26 AM with
Unit Manager Employee E8 revealed that the door to the medication room had a coded lock, further
observation revealed that the code was written on the door jamb.
Interview with unit manager Employee E8 conducted at the time of the observation confirmed that the pass
code of the door lock was written on the door jamb.
Observation of the medication refrigerator located inside the B wing medication room revealed that the
medication refrigerator was not locked. Observation of the contents of the medication refrigerator revealed
a transparent plastic box containing an opened bottle of Lorazepam 2m/ml with 30 ml of liquid inside.
Further, the transparent plastic box containing an opened bottle of Lorazepam 2m/ml with 30 ml of liquid
inside was not permanently affixed to the refrigerator.
Interview with unit manager Employee E8 conducted at the time of the observation confirmed that the
medication refrigerator door was not locked, and that the plastic box containing Lorazepam 2m/ml with 30
ml of liquid inside was not permanently affixed to the refrigerator.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code. 211.12(c) Nursing services
28 Pa. Code 211.12 (d)(1) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395370
If continuation sheet
Page 2 of 2
