Oxford Health Center

In the surveyor’s words

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

• Actual harm, isolatedF600May 24, 2021

  Based on a review of the facility's policy, documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of three residents reviewed (Resident 1) was free of neglect during care which resulted in actual harm by sustaining a right clavicle (the collarbone) fracture due to a fall from a lift. This deficiency is cited as past non-compliance. Findings include: A review of the facility's policy titled, Abuse, Neglect, or Exploitation, dated May 21, 2020, revealed that, each resident is provided with a safe environment where they are not subject to mental, physical, verbal, and sexual abuse. Residents shall also be protected from mistreatment, neglect, exploitation, and misappropriation of property. […]

• Actual harm, isolatedF689May 24, 2021

  Based on review of clinical record and facility documentation, and staff interview, it was determined that the facility failed to provide adequate assistance as indicated on the resident's plan of care related to their transfer status with a mechanical lift which resulted in actual harm of a right clavicle (the collarbone) fracture due to a fall from a lift for one of three residents reviewed (Resident 1). This deficiency is cited as past non-compliance. Findings include: A review of Resident 1's clinical record revealed that the resident had diagnoses that included [CONDITION(S)] affecting the right side (paralysis on right side), history of TIA ([CONDITION(S)] - symptoms similar to a stroke but may come and go), chronic pain and muscle weakness. […]

• No harm, potential for more than minimal, patternF880Mar 2, 2026

  Findings: A review of the facility's policy titled Surveillance for Infection/Infectious Disease, undated, revealed the facility will conduct daily surveillance for reportable infection or outbreak. The nursing staff must notify the Charge nurse of residents with any of the following conditions: Temperature of 100F or greater; Two episodes or more loose watery stools in a twenty-four-hour period; Inflammation or purulent (pus)drainage at the skin; and Transfer to the hospital because of an infection. The DON (Director of Nursing) of Infection Control (IC) Coordinator must enter the data onto the Weekly Surveillance Line Listing Report (A fundamental row-by-row epidemiological tool used in investigation to organize, track, and analyze key information about individual cases). […]

• No harm, potential for more than minimal, isolatedF689Dec 3, 2025

  Based on facility documentation review, clinical record review and staff interviews it was determined the facility failed to prevent accidents for one of one residents reviewed. (Resident 1) Findings Include:Review of Resdient 1's diagnosis sheet revealed a diagnosis of Alzheimer's disease (a progressive brain disorder that causes memory loss and cognitive decline), osteoarthritis (a degenerative joint disease that happens when the protective cartilage in joints wears down, causing pain, stiffness, and reduced movement), and repeated falls.Review of facility incident report dated September 11, 2025, revealed resident was secure in stand-up lift when (they) moved (their) left arm and would not hold onto the bar causing a skin tear to the left forearm.Review of Resident 1's Occupational… […]

• No harm, potential for more than minimal, isolatedF641Jan 16, 2025

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure that resident assessments accurately reflect the residents' status for three of 24 residents reviewed. (Resident 18, Resident 31, and Resident 52). Findings include: Review of Resident 18's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated December 17, 2024, revealed under section N0350 - Insulin, that the resident was marked as receiving insulin medication. Review of Resident 18 physician's orders revealed that the resident was not ordered insulin. Review of the Medication Administration Record (MAR) revealed that the resident did not receive insulin. Interview with the licensed staff, Employee E3, on January 15, 2025, at 1:08 p.m. […]