Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated survey in response to a complaint completed on April 10, 2024, it was determined that Oxford Rehabilitation and Healthcare Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

 Plan of Correction:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Based on a review of facility policy, observation, and staff interview, it was determined that the facility failed to maintain sanitary conditions in the kitchen.

Findings include:

Review of the facility policy entitled, "Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices," dated April 3, 2024, revealed that a beard restraint was to be worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens.

Observations made during a tour of the kitchen on April 10, 2024, at 11:55 a.m., with the Food Service Director, revealed two male dietary aides assisting on the tray line preparing resident lunch trays for delivery to the nursing units. DA1 and DA2 were observed with facial hair and no beard restraints in place.

In an interview on April 10, 2024, at 12:20 p.m., the Food Service Director confirmed that the male dietary aides should have had beard restraints in place as per facility policy.

28 Pa. Code 201.18(b)(3) Management.

28 Pa. Code 211.6(f) Dietary services.

 Plan of Correction - To be completed: 04/24/2024

1. Employees DA1 and DA2 applied beard restraints and were educated on policy.
2. An audit was completed to validate that dietary employees with facial hair were wearing beard restraints were applied. No variances were noted.
3. Dietary staff will be re-educated to wear beard restraints when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens while in the kitchen.
4. NHA/ Designee will complete random weekly audits x4 weeks then monthly x2 to validate dietary staff with facial hair are wearing beard restraints. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.

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