Pennsylvania Department of Health
OXFORD HEALTH CENTER
Patient Care Inspection Results

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OXFORD HEALTH CENTER
Inspection Results For:

There are  140 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
OXFORD HEALTH CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on February 15, 2024, at Oxford Health Center, it was determined the facility was not in compliance 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:


483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:


Based on observations and staff interviews it was determined that the facility failed to ensure the dignity of residents in one of the four units observed (Dementia Unit).

Findings include:

Observation conducted during the environmental tour of the rooms in the Dementia Unit on February 11, 2024, at 10:22 a.m. The observation revealed room [room number] was occupied by two residents. A white paper with a typewritten note indicating "Please use XL (extra-large) pull up with underwear over top and remind resident it's ok to urinate in underwear if can't make it to the bathroom" was posted above Resident 43's bed (A) which was visible to the people walking in the hallway.

Observation conducted on February 15, 2024, at 10:00 a.m., revealed the same message noted above continued to be posted on Resident 43's wall above the bed.

Interview conducted with unlicensed staff, Employee E5, on February 15, 2024, at 10:15 a.m., revealed that the note had been posted on the resident's wall for a couple of weeks now but was not sure who did it.

Interview conducted with the Nursing Home Administrator (NHA) on February 15, 2024, at 1:00 p.m., The NHA confirmed that the note was not posted by the resident's family. The NHA was unable to determine who posted the note mentioned above. The NHA confirmed that resident personal information should have not been posted visible to the public.

The facility failed to ensure the dignity of Resident 43 was maintained by posting private information visible to the public.

28 Pa. Code 201.29(j) Resident Rights

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


 Plan of Correction - To be completed: 03/26/2024

1. The sign located in room of Resident 43 was removed on 2/15/2024
2. Current resident rooms will be inspected for signs that contain private information.
3. Current Community staff will be educated by the NHA or designee to ensure resident dignity, no signs with private information will be posted in resident rooms.
4. NHA or Designee will complete a weekly audit of 5 current resident rooms, then 5 random resident rooms monthly x 2 months for any signage that may contain private information. The results of these audits will be forwarded to the Quarterly Quality Assurance meetings for review and recommendations

483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:


Based upon review of facility policy and procedure and clinical record review, it was determined the facility failed to report to the State agency an allegation of abuse for one of 24 residents reviewed (Resident 28).

Findings include:

Review of facility policy and procedure titled Abuse, Neglect or Exploitation, revised 10/24/2022, revealed "For Skilled Facilities covered under the Elder Justice Act an individual must report any alleged violations of abuse OR if there was serious bodily injury the facility MUST report the allegation to the DOH IMMEDIATELY BUT NO LATER THAN 2 HOURS AFTER THE ALLEGATION IS MADE. For those allegations that are neglect, exploitation, misappropriation of resident property, or mistreatment that do NOT result in serious bodily injury, the facility must report the allegation no later than 24 hours."

Review of Resident 28's clinical progress notes dated December 2, 2023, revealed "CNA's following care plan and two assist with all care. After resident received a bed bath turned to female CNA and stated he is being rough with me. Female CNA reported that she had been present and assisting throughout care. Observed no such behavior. Nurse provided privacy and asked resident the following questions: How was your bed bath? replied ok. Do you feel clean? Replied yes. Are you having any pain or discomfort? replied no. Do you feel safe? replied yes. Made supervisor aware. Revisited resident. Asked the following: Are you ok? replied yes and smiled. Are you happy with the care and bed bath you received? Replied "yes" Are you having any pain or discomfort? Replied no and smiled. Asked if resident need to talk about anything? replied "no, I'm okay". Are you ok with the people that gave you a bed bath? Yes. Do you feel safe? Replied "yes". Supervisor updated."

Review of facility documentation and clinical record failed to reveal evidence the above allegation of abuse was reported to the State agency.

Interview with the Nursing Home Administrator and Director of Nursing on February 15, 2024, at 11:00 a.m. confirmed the above allegation was not reported to the State Agency.

28 Pa. Code 201.18(a)(b)(1)(2)(g)(1) Management





 Plan of Correction - To be completed: 03/26/2024

1. Resident 28 was assessed for injury by RN, no injuries noted.
2. Current resident progress notes will be reviewed for any reports of concern. In the event any are found, they will be reported timely, and full investigation will take place.
3. Health Center staff will be educated by the NHA or designee on Resident Rights, and Abuse Neglect or Exploitation policy, including reporting requirements. Moving forward, the Facility will report any allegations of abuse as per the Facility policy and DOH regulations within the required time frames. The Facility Administration will conduct any investigations and report the findings to DOH and/or any other regulatory entity as required by law or regulation.
4. DON or designee will review the clinical progress notes daily for any allegations of abuse or neglect, and ensure that appropriate notification had occurred for one week. These audits will continue once weekly for 4 weeks, and 5 random days monthly x 2 months. The results of these audits will be forwarded to the Quarterly Quality Assurance meetings for review and recommendations.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:


Based upon review of facility policy and procedure and clinical record review, it was determined the facility failed to thoroughly investigate an allegation of abuse for one of 24 residents reviewed (Resident 28).

Findings include:

Review of facility policy and procedure titled Abuse, Neglect or Exploitation, revised 10/24/2022, revealed "Events involving evidence or reports of physical, sexual, mental or verbal abuse, involuntary seclusion, neglect and misappropriation of resident's property shall be thoroughly investigated including obtaining statements from all potential persons who might have had contact with the resident in the previous 24 ours or within the timeframe that has been identified."

Review of Resident 28's clinical progress notes dated December 2, 2023, revealed "CNA's following care plan and two assist with all care. After resident received a bed bath turned to female CNA and stated he is being rough with me. Female CNA reported that she had been present and assisting throughout care. Observed no such behavior. Nurse provided privacy and asked resident the following questions: How was your bed bath? replied ok. Do you feel clean? Replied yes. Are you having any pain or discomfort? replied no. Do you feel safe? replied yes. Made supervisor aware. Revisited resident. Asked the following: Are you ok? replied yes and smiled. Are you happy with the care and bed bath you received? Replied "yes" Are you having any pain or discomfort? Replied no and smiled. Asked if resident need to talk about anything? replied "no, I'm okay". Are you ok with the people that gave you a bed bath? Yes. Do you feel safe? Replied "yes". Supervisor updated."

Review of facility documentation and clinical record failed to reveal evidence the above allegation of abuse was thoroughly investigated by the facility.

Interview with the Nursing Home Administrator and Director of Nursing on February 15, 2024, at 11:00 a.m. confirmed the above allegation was not thoroughly investigated by the facility.

28 Pa. Code 201.18(a)(b)(1)(2)(g)(1) Management


 Plan of Correction - To be completed: 03/26/2024

1. Resident 28 was assessed for injury by RN, no injuries noted.
2. Current resident progress notes for the last 7 days will be reviewed for any reports of concern. In the event any are found, an incident report will be completed and full investigation will take place in order to rule out abuse or neglect allegations.
3. Current licensed staff will be educated as to the proper process of incident report completion, as well as and Abuse Neglect or Exploitation policy, including reporting requirements.
4. DON or Designee will audit clinical progress notes and incident reports for one week to ensure a full investigation to rule out abuse and neglect has been completed. These audits will be completed on 5 random incident reports weekly, and then monthly x 2 months. The results of these audits will be forwarded to the Quarterly Quality Assurance meetings for review and recommendations.

483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on a review of clinical records and staff interview, it was determined that the facility failed to ensure that assessments accurately reflected the resident's status for two of 24 residents reviewed (Residents 82 and 84).

Findings include:

Review of Resident 82's MDS Assessment (periodic assessment of resident needs) dated January 2, 2024, revealed a discharge status of home/community.

Review of Resident 82's nursing progress notes dated January 2, 2024, at 12:55 p.m., revealed Nurse Practitioner ordered to transfer the resident to the ER (Emergency Room) due to acute left-sided abdominal pain.

Review of the nursing progress notes dated January 2, 2024, at 6:48 p.m., revealed that after the evaluation from [name of hospital] ER, Resident 82 was transferred to another hospital where she/he had previous surgery. The family will be coming to gather personal items.

Interview conducted with the RNAC (Registered Nurse Assessment Coordinator) Employee E3, on February 15, 2024, at 11:00 a.m., confirmed that the Resident was sent to the hospital and was not discharged to home/community on January 2, 2024.

Review of Resident 84's discharge MDS assessment dated November 14, 2023, Section A2105 Discharge Status, indicated that the resident was discharged to an acute hospital.

Review of Resident 84's clinical record including nursing progress note dated November 15, 2023, revealed that the resident was discharged home on November 14, 2023.

During an interview with the RNAC , Employee E3, on February 15, 2024, at 10:08 a.m. confirmed that the resident was discharged home and that the MDS assessment was marked incorrectly.

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 4/20/23


 Plan of Correction - To be completed: 03/26/2024

1.The Assessments for both Resident 82 and 84 were corrected to reflect the appropriate discharge destination on 2/15/2024.
2.The Facility will review the discharge information on the NDA for the residents who were discharged December 1, 2023 through February 29, 2024 to verify the correct discharge disposition.
3.The RNAC(s) will be educated by the NHA to ensure the appropriate discharge destination is indicated on the MDS. Facility will confirm the anticipated discharge destination at the weekly Utilization Review meetings The RNAC will confirm that for any discharges that occurred the prior week.
4.The NHA or designee will audit 5 MDS submissions each month to ensure the appropriate discharge destination was recorded. These audits will be completed monthly for 3 months. The results of these audits will be reported to the QAPI Committee for review and recommendations.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:


Based on review of clinical records and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 18 residents reviewed (Resident 141).

Findings include:

Review of Resident 141's admission MDS (Minimum Data Set - periodic assessment of resident needs) of February 5, 2024, revealed that the resident had an indwelling catheter (flexible tube placed in the bladder to drain urine). Review of the current physician's orders also indicated that the resident had a catheter.

Further review of the clinical record failed to reveal a care plan related to the indwelling catheter.

Interview with Employee E4, corporate representative, on February 15, 2024, at 9:13 a.m. confirmed that a care plan for the catheter was not developed until February 14, 2024.

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.11(a) Resident care plan

28 Pa. Code 211.11(d) Resident care plan

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 4/20/23


 Plan of Correction - To be completed: 03/26/2024

1. The Care Plan for Resident 141 has been updated to reflect an indwelling catheter.
2. A review of current residents in the facility will be conducted to verify that all residents with an indwelling catheter were identified and that the proper care plan was in effect.
3. Education will be provided to the licensed staff by the DON to ensure that a comprehensive care plan is developed to include indwelling catheters.
4. New admissions will be reviewed by DON or designee to ensure a comprehensive care plan for indwelling catheter is in medical record as needed. These audits will be completed on 5 random admissions weekly x 4 weeks, and monthly x 2 months. The results of these audits will be forwarded to the Quarterly Quality Assurance meetings for review and recommendations.


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