Pennsylvania Department of Health
OXFORD HEALTH CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

OXFORD HEALTH CENTER
Inspection Results For:

There are 149 surveys for this facility. Please select a date to view the survey results.

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OXFORD HEALTH CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Findings of an Abbreviated Licensure Complaint Survey completed on October 28, 2025, at Oxford Health Center, identified deficient practice, related to the reported complaint allegations, under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

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 therapy notes dated September 8, 2025 revealed Resident 1 "trialed in the stand up lift with standing tolerance of less than 30 sec (seconds) due to being anxious with standing. She needed assistance of 1 person to fix her feet on the platform for the lift going to bed, did not need assistance going back to wheelchair. Cues provided throughout to keep BLE (bilateral lower extremities or both feet) on the platform."

Further review of Resident 1's incident report dated September 11, 2025 revealed a statement dated September 12, 2025 by licensed therapy employee E3, stating "This OT discussed with the RN (Registered Nurse) on the unit that (Resident 1) is to stay a 2-person transfer for safety. In the event that she requires or may need a sit-to-stand up lift, it can only be done by CNAs familiar with her behavior and who has been educated as she tends to pull her fee back off the lift and requires readjustment and constant cues."

Review of the incident report dated September 11, 2025 revealed a statement obtained from Nursing Employee E1 on September 12, 2025 stating "I helped Nursing Employee 2 transfer (Resident 1) on the night in question. Typically nursing creates and updates the (assignment) sheets for CNAs ... to know transfer statuses without having to log into the computer. I thought (OT) had said she was clear for a sit to stand lift about 2 weeks ago."

An interview on October 28, 2025, at approximately 2:44 p.m. with Nursing Employee E1 revealed they assisted with the transfer and when they came into the resident's room, the resident was already in the lift. The resident wasn't holding arm rests during the transfer, but when the resident was unclipped from the lift, she witnessed the skin tear. She did not witness any other injury, and the resident was placed in bed."
An interview with the Nursing Home Administrator on 10/28/25 at approximately 2:00 PM revealed that the facility conducts competency evaluations to all direct care staff on hire and annually.
Review of Employee E1's new hire competency record dated July 3, 2025 revealed that the CNA who assisted with the transfer had been assessed as competent to transfer residents using mechanical lifts. This interview also revealed that the facility provides an orientation to all agency staff and they must be deemed competent to use the mechanical lifts.
The facility failed to ensure that the assignment sheet accurately reflected the care needs of Resident 1 for staff to follow while transferring.

28 Pa. Code 211.11(d) Resident care plan

28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Plan of Correction - To be completed: 12/05/2025

1. Resident 1 Care plan was updated to reflect care needs to the Kardex (assignment sheet).
2. An audit was completed of current residents to ensure that care plan and Kardex accurately reflect the care needs.
3. The Director of Nursing or designee provided re-education to nursing staff on creating care plans and linking with the Kardex to accurately reflect the care needs of the residents.
4. The Director of Nursing or designee will complete an audit of 5 random resident care plan transfer interventions to ensure the Kardex accurately reflects the care needs will be completed weekly for four weeks, and an audit of 5 random resident care plan transfer interventions to ensure the Kardex accurately reflects the care needs will be completed monthly for two months. These audits will be forwarded to Quarterly Quality Assurance meetings for review and recommendations.

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