Oxford Health & Rehab Center

In the surveyor’s words

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

• Immediate jeopardy, patternF880Apr 29, 2021

  Based on observation, staff interview, physicians' interview, review of the manufacturer's instructions for glucose meter (glucometer), insert for germicidal wipes used at the facility, resident record review, and facility policy review, the facility (a.) failed to ensure nursing staff cleaned and disinfected a multi-use glucometer before and after fingerstick blood glucose testing for three (3) of five (5) sampled residents observed for blood glucose fingersticks, Residents #15, #27, and #122 and (b.) failed to perform proper hand hygiene and glove use for (4) of 5 sampled residents, Residents #15, #27, #122, and #230 and (c.) failed to use a barrier and perform hand hygiene for one (1) of 5 sampled residents observed during blood glucose monitoring for Residents #230. […]

• Actual harm, isolatedF656Mar 12, 2026

  Based on observation, record review, resident and staff interviews, the facility failed to develop and implement comprehensive, person-centered care plans for three (3) of twenty-four (24) residents reviewed (Residents #5, #17, and #84). Specifically, the facility failed to develop care plan interventions addressing a physician-ordered fluid restriction for a resident receiving hemodialysis, failed to ensure the safe implementation of care plan interventions for a resident receiving Percutaneous Endoscopic Gastrostomy (PEG) tube feedings, and failed to develop and implement a care plan addressing a resident's repeated refusal of physician-ordered weights. […]

• Actual harm, isolatedF698Mar 12, 2026

  Based on resident interview, record review, and staff interviews, the facility failed to ensure fluid restrictions were implemented and monitored for one (1) of six (6) residents reviewed for dialysis services, resulting in fluid volume overload that required a hospitalization. (Resident #5). Findings include:The facility did not provide a policy related to monitoring or implementing fluid restrictions for residents.Review of a statement on facility letterhead dated 3/11/26 and signed by the Administrator revealed (Proper Name of Facility) does not have a policy related to fluid restrictions or management of fluids. […]

• Actual harm, isolatedF697Oct 2, 2025

  Based on resident representative and staff interview, record review, and facility policy review, the facility failed to ensure pain management was provided for a resident that had diagnoses that included pain and chronic pain for one (1) of six (6) residents sampled. Resident #1Findings include:Record review of facility policy titled, Pain Management with a revised date of 3/10/25, revealed, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences .During a phone interview on 10/1/25 at 12:17 PM, Resident #1's representative revealed the resident had multiple wounds and was on antibiotics and was admitted to the… […]

• No harm, potential for more than minimal, widespreadF812May 12, 2023

  Based on observation, staff interviews and facility policy review the facility failed to ensure items in the kitchen refrigerator and freezer were dated and labeled for one (1) of three (3) dietary observations. Findings include: A review of the facility policy titled, Food Storage with an initial date of 2021 and a revision date of ,d+[DATE] revealed All foods should be covered, labeled, and dated, and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. On [DATE] at 10:15 AM, observation and interview of the kitchen with the Dietary Manager (DM) and Dietary Staff #1 revealed in the standing freezer noted a manufactured bag of a food product that was unlabeled and undated. […]