Birchwood Rehab: Oxygen Tank Empty, No Trach Orders - PA

Inspectors from the Centers for Medicare and Medicaid Services visited Birchwood Rehabilitation and Healthcare Center on March 28, 2026, and found Resident 38 in her room at 11:15 in the morning, nasal cannula in place, oxygen tubing running to a tank that held nothing. She had a physician order dating back to February 3 requiring continuous oxygen at four liters per minute. The word continuous means without interruption.

A registered nurse, identified in the inspection report as Employee 4, confirmed the tank was empty when inspectors pointed it out and swapped it for a full one. The nurse checked the resident's vitals. Oxygen saturation came back at 94 percent. Heart rate was 62. Skin color looked normal. No visible distress.

Those numbers offered some reassurance. They did not explain how long the tank had been empty before an outside inspector happened to walk into the room.

The Director of Nursing and the Nursing Home Administrator were told about the finding the following day, March 29. The inspection report states flatly that the facility failed to ensure Resident 38 received oxygen continuously in accordance with physician orders. No further explanation was offered in the record.

The second violation involved a different kind of failure, one that had been building longer.

Resident 81 has a tracheostomy, a surgically created opening in the neck through which she breathes, and a radiation ulceration beneath the tracheostomy plate, a wound caused by tissue damage from radiation therapy. A contracted nurse practitioner documented that wound on March 4. Staff were treating it twice daily with antiseptic-soaked gauze covered by bordered gauze.

When inspectors spoke with Resident 81 on March 30, she said staff had been performing tracheostomy care daily and that the wound was almost healed. She reported no pain. By her own account, the care was happening.

What the facility could not produce was any documentation that it was.

No physician orders for tracheostomy care. No consistent records showing licensed nursing staff had performed the procedure according to professional standards or facility policy. The Director of Nursing reviewed the findings with inspectors on March 31 and confirmed both gaps. The orders weren't there. The documentation wasn't there.

Tracheostomy care is not optional or informal. The opening requires regular cleaning to prevent infection and to keep the airway clear. A radiation ulceration at the same site adds complexity. Tissue damaged by radiation heals differently and is more vulnerable to breakdown and infection. Treating that wound without physician orders means no one has formally assessed the treatment plan, authorized it, or taken responsibility for it in the medical record.

The resident told inspectors she was nearly healed. The record could not confirm she had received the care that got her there.

CMS assigned both violations a harm level of minimal harm or potential for actual harm. That classification reflects what inspectors could document at the moment of the visit. Resident 38's oxygen saturation was 94 percent when the nurse finally checked. Resident 81 said she felt no pain. The inspection report does not say either resident suffered a measurable injury.

What it does say is that a woman who cannot breathe without supplemental oxygen was left with nothing to breathe from, and that a woman with a surgical airway and an open radiation wound was receiving treatment that existed, as far as the medical record was concerned, nowhere.

Birchwood Rehabilitation and Healthcare Center is a long-term care facility in Luzerne County. The inspection was conducted in response to a complaint.

Resident 38 sat in her wheelchair that Friday morning, the cannula resting in her nostrils, the tubing connected to an empty tank, waiting for someone to come.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Birchwood Rehabilitation & Healthcare Center from 2026-03-31 including all violations, facility responses, and corrective action plans.

Additional Resources

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