Oxford Rehabilitation & Health Care Center

In the surveyor’s words

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

• Actual harm, patternF600Feb 27, 2025

  Based on observation, record review and interview, the facility failed to protect one Resident (#92), from neglect, out of a total sample of 25 residents. Specifically, the facility neglected to schedule a follow-up appointment for over ten months when a physician's order was written for a Gastrointestinal Doctor consult to determine a possible colostomy (a surgical procedure that creates an opening (stoma) in the abdominal wall to divert stool from the colon directly into a bag or pouch) reversal procedure resulting in emotional distress. […]

• Actual harm, isolatedF695May 11, 2023

  Based on observations, record review and interview, the facility failed to ensure Residents received oxygen according to professional standards of practice and in accordance with physician's orders for 1 Resident (#23) out of a total sample of 33 residents. Findings include: Resident #23 was admitted to the facility in June 2022 with diagnoses that include chronic obstructive pulmonary disease, acute and chronic respiratory failure, morbid obesity and heart failure. Review of Resident #23's most recent Minimum Data Set (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 15 out of a possible 15 indicated that he/she is cognitively intact. […]

• Actual harm, isolatedF692Jun 24, 2022

  Based on observation, record reviews, and interviews, the facility failed to maintain acceptable parameters of nutritional status by not providing adequate evaluation and interventions to maintain body weight and prevent significant weight loss or gain for 4 Residents (#46, #69, #158, and #306), out of a total sample of 25 residents. Findings include: Review of the facility's policy titled Weight Monitoring, dated August 2015, indicated that if a significant weight loss/gain is identified (>5% in 30 days or >10% in 6 months) the IDT (interdisciplinary team), dietician, physician, and family are notified. Further review indicated that all residents with a significant weight loss are reviewed weekly by the IDT for appropriateness of the interventions implemented. […]

• Actual harm, isolatedF600Sep 1, 2021

  Based on records reviewed, interviews, and review of Facility surveillance camera video footage, for one of three sampled residents (Resident #1) the Facility failed to ensure he/she was free from abuse by staff. On 07/21/21, Resident #1, who was known by staff to have exhibited inappropriate behaviors, came up behind Certified Nurse Aide (CNA) #1 and touched her buttocks. CNA #1 immediately swung her arm around slapping Resident #1 on his/her right upper arm. CNA #1 also swore at and in a threatening manner, told Resident #1 to not do that again. Findings include: The Facility's Policy titled, Abuse Prohibition Policy, dated December 2016, indicated the Facility had the responsibility to ensure that each resident had the right to be free from abuse. […]

• No harm, potential for more than minimal, widespreadF812Feb 12, 2026

  Based on observation, record review, and interview the facility failed to appropriately monitor the effective use of a low temperature dish machine. Specifically, the facility failed to document the parts per million (PPM) of the sanitizing solution, to ensure effective sanitization. Findings include: Review of the current manufacturer's guidelines, for the facility's contracted dish machine maintenance company, indicated that chemical sanitization PPM should be checked with daily test strips. During an observation on 2/11/26 at 11:56 A.M., the dish machine in the kitchen ran a wash cycle at 126 degrees Fahrenheit and a rinse cycle at 176 degrees Fahrenheit. The staff member in the dish machine area said that the dish machine used chemicals to clean the dishes in the machine. […]