Pennsylvania Department of Health
OXFORD REHABILITATION AND HEALTHCARE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 44 surveys for this facility. Please select a date to view the survey results.

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OXFORD REHABILITATION AND HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000
Based on an Emergency Preparedness Survey completed on November 18, 2025, at Oxford Rehabilitation and Healthcare Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000
Facility ID# 014002

Building 01

Main Building

Based on a Medicare/Medicaid Recertification Survey completed on November 18, 2025, it was determined that Oxford Rehabilitation and Healthcare Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a three-story, Type II (222) fire resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

Least serious 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 has the potential for causing no more than a minor negative impact on the resident.

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100 28 Pa. Code 553.3(1) GOVERNING BODY RESPONSIBILITIES Governing body responsibilities include: (1) Conforming to applicable Federal, State and local law. This REGULATION has not been met. 35 P.S. 448.808. Issuance of license. (a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met: (2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered. Based on observation, document review and interview, it was determined the following items did not conform to applicable Federal, State and local laws and regulations. Findings include: 1. Observation and document review on November 18, 2025, at 9:30 a.m. revealed the facility failed to secure plan approval by the Department of Health prior to the alterations in conference room A. Contractors were observed onsite working in this space at time of survey. Exit Interview with the Administrator and Maintenance Director on November 17, 2025, at 11:45 a.m., confirmed the facility failed to obtain Department of Health approval. 2. Observation and documentation review on November 18, 2025, at 10:00 a.m. revealed the facility failed to secure plan approval by the Department of Health prior to the alterations to the shower rooms located on 1st, 2nd, and 3rd floors. The rooms were gutted at time of survey. Exit Interview with the Administrator and Maintenance Director on November 18, 2025, at 11:45 a.m., confirmed the facility failed to obtain Department of Health approval. 3. Observation and documentation review on November 18, 2025, at 10:15 a.m. revealed the facility failed to secure plan approval by the Department of Health prior to the alterations to the Nurses Station and offices located on 2nd floor. The area was barriered, and Nurses were working from a temporary open space at time of survey. Exit Interview with the Administrator and Maintenance Director on November 18, 2025, at 11:45 a.m., confirmed the facility failed to obtain Department of Health approval.

Plan of Correction - To be completed: 12/29/2025

"This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report."

1. Barrier to nurses station was removed from 2nd floor nurses station.
2. The facility sent plans were submitted to plan review through the SharePoint Library for the Conference Room, Shower Rooms, and the 2nd floor nurses station
3. Inservice completed with Administrator by RDO on ensuring that communication is sent to Plan review prior to completing any updates to existing areas in the facility.
4. Audits to be completed 3x per week x4 weeks that any updates to existing areas in the facility have corresponding communication to plan review. 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.

NFPA 101 STANDARD Multiple Occupancies - Construction Type:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. 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. This deficiency was not found to be throughout this facility.

Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0133 Based on observation and interview, it was determined the facility failed to maintain the fire resistance of fire barriers, affecting one of four levels Observation on November 18, 2025, at 11:00 a.m., revealed an open penetration above the fire doors, on the first floor, by the elevators. Exit Interview with the Administrator and Maintenance Director on November 18, 2025, at 11:45 a.m., confirmed the open penetration.

Plan of Correction - To be completed: 12/29/2025

1. Penetrations identified to the smoke barriers on each floor were filled with the appropriate fire barrier sealant CP 25WB+.
2. Education completed with maintenance staff to ensure all Fire barrier are properly sealed with no penetrations
3. Audits to be completed 3x per week x4 weeks of fire barrier walls in the facility to ensure that there are no penetrations and any identified penetrations are properly sealed. 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.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225 Based on observation and interview, it was determined that the facility failed to maintain stair towers, affecting one of three stairways. Findings include: 1. Observation on November 18, 2025, at 10:30 a.m., revealed signage was stored within the 2nd floor stair tower by the elevator. Exit Interview with the Administrator and Maintenance Director on November 18, 2025, at 11:45 a.m., confirmed the storage in the stair tower.

Plan of Correction - To be completed: 12/29/2025

1. Signage that was identified in the smoke tower was immediately removed at the time of the survey.
2. Initial Audit completed of all Stair towers to ensure that are clear of any obstructions.
3. Education completed with maintenance staff to ensure all stair towers are clear of any obstructions.
4. Audits to be completed 3x per week x4 weeks of stair towers to ensure that they are clear of any obstructions. 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.

NFPA 101 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291 Based on document review and interview, it was determined the facility failed to ensure battery back-up lighting was maintained in operable condition, affecting two of four levels. Findings include: 1. Document Review on November 18, 2025, at 8:30 a.m., revealed the January 2025 Emergency Lighting Inspection indicated 3- battery backup lighting units failed the 90-minute annual test. Evidence of corrective action was unavailable at time of survey. Exit Interview with the Administrator and Maintenance Director on November 18, 2025, at 11:45 a.m., confirmed the missing documentation.

Plan of Correction - To be completed: 12/29/2025

1. Identified Emergency Light that failed annual inspection was replaced with corresponding work order for completion of work.
2. Audit of all emergency lights completed to ensure that they are working properly
3. Education completed with maintenance staff on ensuring that all Emergency lights are working properly
4. Audits to be completed 3x per week x4 weeks of Emergency lights to ensure that they are working properly. 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.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321 Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of hazardous areas, in sprinklered locations, affecting one of four levels. Findings Include: Observation on November 18, 2025, at 10:35 am, revealed, 2nd floor storage room had multiple open hole penetrations along the side wall. The room is greater than 50 square feet and contains combustible items. Exit Interview with the Administrator and Maintenance Director on November 18, 2025, at 11:45 a.m., confirmed the penetrations.

Plan of Correction - To be completed: 12/29/2025

1. Penetrations identified in 2nd floor storage room were repaired with new sheetrock.
2. Full house audit completed of all storage rooms to ensure that there are no penetrations.
3. Education completed with maintenance staff on ensuring that all storage rooms greater than 50 square feet containing any combustible items do not have any penetrations in the walls.
4. Audits to be completed 3x per week x4 weeks of facility storage rooms to ensure that the walls have no penetrations. 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.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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.

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345 Based on document review, observation, and interview, it was determined the facility failed to maintain fire alarm system components, affecting the entire facility. Findings include: 1. Document review on November 18, 2025, at 8:30 a.m., revealed June 20, 2025, Fire Alarm Inspection Report listed the following deficiency, which remained uncorrected at time of survey. (The deficiency was also cited on January 15, 2025, Fire Alarm Inspection Report.) a. "Elevator devices were not tested at this visit due to maintenance not having the elevator reset key. Customer needs to obtain a new key and finish testing devices and service update the report." Exit Interview with the Administrator and Maintenance Director on November 18, 2025, at 11:45 a.m., confirmed the fire alarm deficiency.

Plan of Correction - To be completed: 12/29/2025

1. Tilley's called out to reinspect the Fire Alarm and clear identified deficiency.
2. Educations completed with Maintenance Director on ensuring that any identified Deficiencies mentioned on the fire alarm report are followed up and resolved with appropriate documentation.
3. Audits to be completed 3x per week x4 weeks of Fire alarm inspection reports to ensure that any identified deficiencies are corrected. 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.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355 Based on observation and interview, it was determined that the facility failed to ensure that portable fire extinguishers had monthly quick checks conducted and documented, on one of five levels. Findings include: 1. Observation on November 18, 2025, at 10:00 a.m., revealed the wall mount portable fire extinguisher in 3rd floor dining room was missing its October monthly quick check. Exit Interview with the Administrator and Maintenance Director on November 18, 2025, at 11:45 a.m., confirmed the missing quick check.

Plan of Correction - To be completed: 12/29/2025

1. Full House audit completed of all Fire Extinguishers to ensure that all Quick Checks are up to date and in place.
2. Educations completed with maintenance staff on ensuring that all Fire Extinguisher quick checks are completed and documented
3. Audits to be completed 3x per week x4 weeks of fire extinguishers to ensure that Quick checks are completed and documented. 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.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372 Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations affecting one of four levels. Findings include: 1. Observation on November 18, 2025, revealed unsealed penetrations of smoke barrier walls in the following locations: a. 10:15 am, above smoke doors by room 313, around MC wire. b. 10:20 am, above smoke doors by room 323, open penetration. Exit Interview with the Administrator and Maintenance Director on November 18, 2025, at 11:45 a.m., confirmed the unsealed penetrations.

Plan of Correction - To be completed: 12/29/2025

1. Identified Smoke penetrations were properly sealed using fire barrier sealant CP 25WB+ which is rated for through penetration based on manufacturer guidelines.
1. Full house audit completed throughout facility to ensure that all penetrations were properly sealed.
2. Education completed with maintenance staff to ensure all smoke barrier wall are properly sealed with no penetrations
3. Audits to be completed 3x per week x4 weeks of smoke barrier walls in the facility to ensure that there are no penetrations and any identified penetrations are properly sealed. 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.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761 Based on document review and interview, it was determined the facility failed to properly document the required annual fire door inspection, affecting one required inspection. Findings include: 1. Document review on November 18, 2025, at 8:30 a.m., revealed the facility could not produce documentation showing that an annual fire door inspection was completed as required. Exit Interview with the Administrator and Maintenance Director on November 18, 2025, at 11:45 a.m., confirmed documentation of the annual rated door inspection was incomplete at time of survey.

Plan of Correction - To be completed: 12/29/2025

1. Annual Fire Door inspection was completed by Maintenance Director
2. Education completed with maintenance staff on ensuring that Fire door inspections are completed Annually and documented on approved form.
3. Audits to be completed 3x per week x4 weeks of Fire Door Inspection paperwork to ensure that is properly completed. 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.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923 Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of medical gas rooms, in sprinklered locations, affecting one of four levels. Findings include: 1. Observation on November 18, 2025, at 11:40 am, revealed the 1st floor Oxygen Storage Room door had a gap at the top of door, handle side. Exit Interview with the Administrator and Maintenance Director on November 18, 2025, at 11:45 a.m., confirmed the missing rated door hardware.

Plan of Correction - To be completed: 12/29/2025

1. 1st floor oxygen storage room door was adjusted to ensure that the door was free of any gaps
2. Audits completed of all oxygen storage room doors to ensure that they are free of any Gaps
3. Educations completed with Maintenance staff to ensure that all oxygen storage room doors are free of any gaps
4. Audits to be completed 3x per week x4 weeks of Oxygen room storage doors to ensure that they are free of any gaps. 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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