Diversicare of Oxford

In the surveyor’s words

From the most serious findings on record at Diversicare of Oxford, in the surveyor’s own words.

• Immediate jeopardy, patternF689Apr 9, 2026

  Based on interviews, record review, review of Facility Reported Incidents (FRIs), review of the facility's investigative file and review of a facility policy titled, Elopement, the facility failed to ensure Resident Identifiers (RI) #119, RI #88, RI #127, and RI #106 received supervision in a manner to ensure their whereabouts were known to the facility and the residents were in an environment free of accident hazards, failed to ensure its Wander Guard system alerted staff when RI #119 exited the facility, and failed to ensure RI #106 was supervised in a manner to prevent elopement after becoming agitated and stating he/she wanted to leave.The facility further failed to implement and follow fall precautions interventions for RI #60 a resident identified at risk for falls. […]

• No harm, potential for more than minimal, widespreadF688Apr 9, 2026

  Based on record review, interview and policy titled Restorative Guidelines the facility failed to implement a functional maintenance program (FMP) following discharge from therapy for Resident Identifier (RI) #60 one of one residents who experienced multiple falls. This failure had the potential to contribute to decline in function and increased risk for further falls and had the potential to affect all residents requiring ongoing maintenance services due to the absence of a functional maintenance program. […]

• No harm, potential for more than minimal, widespreadF725Apr 9, 2026

  Based on interview, record review and the Center Assessment Tool the facility failed to provide sufficient nursing staff to meet resident needs when the Registered Nurse (RN) #40 did not respond to a residents call light or notification of a fall, stating she did not have time because she was responsible for 50 residents. In addition, the facility did not have a restorative program to ensure residents maintained mobility and range of motion in place due to lack of staffing availability. These failures limited the facility's ability to provide timely care and services and had the potential to affect all residents who require nursing supervision and restorative services. […]

• No harm, potential for more than minimal, patternF600Apr 9, 2026

  Based on interviews, reviews of residents' medical records, review of a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, review of Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative files, the facility failed to protect the rights of residents to be free from abuse perpetrated by an employee of the facility and by other residents in the facility. Specifically: 1) On 08/05/2025 Resident Identifier (RI) #70 was physically abused by RI #106 and RI #126, when RI #106 and RI #126 struck RI #70 in the chest with their open hands. The facility failed to protect RI #70 from physical abuse. […]

• No harm, potential for more than minimal, patternF867Apr 9, 2026

  Based on interviews, record review, and a review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI), the QAPI committee failed to identify all causal factors related to four elopements for Resident Identifiers (RI) #119, RI #88, RI #127 and RI #106 and to determine what corrective actions needed to be taken to prevent any further resident safety concerns.This deficient practice affected RI #119, RI #88, RI #127 and RI #106.These deficient practices were cited as a result of the investigations of facility reported incident/complaint/report numbers 447995, 447964, 2629802 and 2603429.Findings Include: Cross-Reference F689 and F725, A review of a facility policy titled, Quality Assurance and Performance Improvement, dated March 2025 revealed: Purpose The… […]