Oak Glen Healthcare And Rehabilitation Center
OAK GLEN HEALTHCARE AND REHABILITATION CENTER in LEWISBURG, PA — inspection on August 22, 2025.
Found 11 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Federal health inspectors cited OAK GLEN HEALTHCARE AND REHABILITATION CENTER in LEWISBURG, PA for a deficiency under regulatory tag F-F0550 during a standard health inspection conducted on 2025-08-22.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of OAK GLEN HEALTHCARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-21.
Federal health inspectors cited OAK GLEN HEALTHCARE AND REHABILITATION CENTER in LEWISBURG, PA for a deficiency under regulatory tag F-F0559 during a standard health inspection conducted on 2025-08-22.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of OAK GLEN HEALTHCARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-21.
Federal health inspectors cited OAK GLEN HEALTHCARE AND REHABILITATION CENTER in LEWISBURG, PA for a deficiency under regulatory tag F-F0585 during a standard health inspection conducted on 2025-08-22.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of OAK GLEN HEALTHCARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-21.
Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide assistance with activities of daily living (ADL) for dependent residents for two of two residents reviewed for ADL concerns (Residents 107 and 90).
Findings include: Clinical record review for Resident 107 revealed that the facility admitted him on August 14, 2025 (Thursday).
Observation of Resident 107 on August 20, 2025, at 11:09 AM revealed that his hair appeared uncombed and oily. Resident 107 presented with facial hair indicative of numerous days without shaving.
Interview with Resident 107 on the date and time of the observation revealed that he had not received a shower yet at the facility. Resident 107 also confirmed that no staff had assisted him with shaving since his admission to the facility. Resident 107 stated that on this day, nursing staff supplied him with shaving equipment.
Interview with Employee 8 (licensed practical nurse) on August 20, 2025, at 11:10 AM confirmed that she provided Resident 107 shaving equipment on this date.
Review of a Documentation Survey Report (electronic documentation of resident care needs completed by nurse aide staff) dated August 2025 revealed that Resident 107 was to receive a shower on Wednesday and Saturday evenings.
Nurse aide staff did not document the provision of a shower until August 20, 2025, at 11:42 PM (following the surveyor's observation). Resident 107 was totally dependent on the physical assistance of two staff for the shower.
There was no evidence that staff offered Resident 107 a shower before August 20, 2025. Resident 107 did not receive a shower on Saturday, August 16, 2025.
The surveyor reviewed the above concerns regarding Resident 107's assistance with ADL needs during an interview with the Nursing Home Administrator, Director of Nursing, and Employee 5 (assistant director of nursing) on August 21, 2025, at 2:00 PM.
Observation of Resident 90 on August 20, 2025, at 12:33 PM revealed he was sitting at the dining room table for lunch with very scruffy whiskers extending from his lip, cheeks, and down to his neck.
The resident stated he needed to shave.
Clinical record review for Resident 90 revealed a quarterly MDS (minimum data set, an assessment completed at periodic intervals of time to assess resident care needs), dated July 22, 2025, which indicated facility staff assessed the resident as requiring partial/moderate assistance for personal hygiene and the resident had a BIMS (brief interview of mental status) score of two, indicating severe cognitive impairment. Resident 90's facial hair was reviewed with the Nursing Home Administrator and Director of Nursing on August 20, 2025, at 3:32 PM. In a follow up observation of Resident 90 on August 21, 2025, at 12:18 PM he was seated at a dining room table eating lunch. It appeared the resident's face and neck had been shaved but remained spotty with whiskers in areas of his face and lip. Resident 90 indicated, They shaved me this morning. Resident 90 stated, I like a clean shave, that is how I did it at home, and has a young chap.
That is how we had to be on the farm.
The above findings for Resident 90 were reviewed with the Nursing Home Administrator and Director of Nursing on August 21, 2025, at 2:20 PM. 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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Oak Glen Healthcare and Rehabilitation Center
15 Ridgecrest Circle Lewisburg, PA 17837
SUMMARY STATEMENT OF DEFICIENCIES
Review of an incident investigation dated July 27, 2025, at 8:40 PM revealed that the Director of Nursing initiated the investigation.
There was no clinical record progress note documentation completed on July 27, 2025, that indicated Resident 15 left the facility unattended (eloped) in accordance with the facility policy that stipulated, When a departing individual returns to the facility, the charge nurse shall examine the resident for injuries, notify the attending physician, notify the resident's representative of the incident, complete and file Report of Incident/Accident, and document the event in the resident's medical record. An Elopement Evaluation completed by the Director of Nursing on July 28, 2025, at 9:56 AM indicated that Resident 15 wandered aimlessly or was non-goal-directed, but he did not have a pattern of wandering behavior and his wandering behavior was not likely to affect the safety or well-being of himself or others (despite the above documentation of his wandering behavior in other residents' rooms, outside the nursing unit, and unsuccessful and successful attempts to leave the building).
The assessment also indicated that his wandering behavior was not likely to affect the privacy of others.
Incident note documentation dated July 29, 2025, at 12:39 PM indicated that the interdisciplinary team reviewed an incident that staff observed Resident 15 in the facility parking lot and that he was immediately returned to the nursing unit by staff and placed on Q (every) 15 minute checks for 24 hours to monitor behaviors.
The facility alarmed the main exit/entrance door to the nursing unit and placed stop signs on the doors.
The documentation specifically reiterated that, Prior to incident resident was not identified as an elopement risk.
An Elopement Evaluation dated August 5, 2025, at 9:12 PM continued to indicate that Resident 15's wandering behavior was not likely to affect the safety or well-being of himself or others or affect the privacy of others even though he exhibited the behavior and presented the potential to wander in and out of other residents' rooms.
Despite several documented entries of Resident 15's wandering behavior that included wandering in and out of resident rooms, interrupted attempts to leave the nursing unit, and exiting the nursing unit to the unsecured main lobby, the facility did not identify Resident 15 as an elopement risk until staff found him in the parking lot of the facility.
The surveyor reviewed with above concerns with the Nursing Home Administrator, Director of Nursing, and Employee 5 on August 21, 2025, at 2:00 PM. 28 Pa.
Code 211.10(d) Resident care policies 28 Pa.
Code 211.12(d)(1)(5) Nursing services
Facility ID:
Federal health inspectors cited OAK GLEN HEALTHCARE AND REHABILITATION CENTER in LEWISBURG, PA for a deficiency under regulatory tag F-F0726 during a standard health inspection conducted on 2025-08-22.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of OAK GLEN HEALTHCARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-21.
Federal health inspectors cited OAK GLEN HEALTHCARE AND REHABILITATION CENTER in LEWISBURG, PA for a deficiency under regulatory tag F-F0802 during a standard health inspection conducted on 2025-08-22.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of OAK GLEN HEALTHCARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-21.
Federal health inspectors cited OAK GLEN HEALTHCARE AND REHABILITATION CENTER in LEWISBURG, PA for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-22.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of OAK GLEN HEALTHCARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-21.
Federal health inspectors cited OAK GLEN HEALTHCARE AND REHABILITATION CENTER in LEWISBURG, PA for a deficiency under regulatory tag F-F0842 during a standard health inspection conducted on 2025-08-22.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of OAK GLEN HEALTHCARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-21.
Federal health inspectors cited OAK GLEN HEALTHCARE AND REHABILITATION CENTER in LEWISBURG, PA for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-22.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of OAK GLEN HEALTHCARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-21.
Federal health inspectors cited OAK GLEN HEALTHCARE AND REHABILITATION CENTER in LEWISBURG, PA for a deficiency under regulatory tag F-F0883 during a standard health inspection conducted on 2025-08-22.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Develop and implement policies and procedures for flu and pneumonia vaccinations.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of OAK GLEN HEALTHCARE AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-21.