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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review, facility policy review, resident interview, and staff interview, it was determined that the
facility failed to ensure that a physician's order was followed for one of five residents. (Resident 1)
Residents Affected - Few
Findings include:
Review of the facility policy entitled, Administering Medications, dated March 8, 2023, revealed that
medications are to be administered in a safe and timely manner, and as prescribed. Further, medications
are administered in accordance with prescriber orders, including any time frame.
Clinical record review revealed that Resident 1 was admitted on [DATE], with diagnoses that included
diabetes (insufficient production of insulin, causing high blood sugar). Review of the Minimum Data Set
assessment dated [DATE], revealed the resident had no memory impairment and received a medication to
treat diabetes. Review of a physician order dated April 27, 2023, directed staff to administer a medication to
treat diabetes (Trulicity injection) once a week on a Friday. Review of the Medication Administration Record
for May 2023, revealed that staff had administered the Trulicity medication on Wednesday, May 3, 2023, two
days prior to the next scheduled dose. Resident 1 notified administration that she received the injection on
Wednesday, May 3, 2023, and Friday, May 5, 2023. During an interview on May 9, 2023, at 11:35 a.m., the
Resident stated that the injection was adminstered twice last week.
In an interview on May 9, 2023, at 2:30 p.m., the Director of Nursing confirmed that staff failed to follow the
physician's order.
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:
395710
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
395710
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/09/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oxford Rehabilitation and Healthcare Center
300 East Winchester Ave
Langhorne, PA 19047
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure
that each resident was offered medication as prescribed by the physician for one of five residents.
(Resident 2)
Findings include:
Review of the facility policy entitled, Unavailable Medications Policy, dated March 8, 2023, revealed that
staff was to notify the physician of an unavailable medication, report the date of expected availability, and
obtain a hold order for the unavailable medication if the physician wanted the medication administered
when received from the pharmacy.
Clinical record review revealed that Resident 2 had diagnoses that included diabetes (insufficient
production of insulin, causing high blood sugar). Review of the Minimum Data Set assessment dated
[DATE], revealed the resident had no memory impairment and received medication to treat diabetes. A
physician order dated April 27, 2023, directed staff to administer a medication to treat diabetes (dulaglutide
injection) once weekly on Mondays. Review of the Medication Administration Record (MAR) for May 8,
2023, revealed the resident did not receive the medication on May 8, 2023 as it was not available form the
pharmacy. There was no documentation to support that the physician was notified that the medication was
unavailable for administration.
In an interview on May 9, 2023, at 2:30 p.m., the Director of Nursing stated the medication was not
available from the pharmacy to be administered and the physician should have been notified per facility
policy.
28 Pa. Code 211.10(c) Resident care policies.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395710
If continuation sheet
Page 2 of 2
