Deficiency Records for The Oxford Rehabilitation and Health Care Center
Updated as of March 01, 2020
This is not the most recent data for The Oxford Rehabilitation and Health Care Center. For the most recent information, click here.
A list of the most recent deficiencies for The Oxford Rehabilitation and Health Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-03 | 2019-11-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-10-24 | 2019-11-04 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-24 | 2019-11-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-24 | 2019-11-04 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-10-24 | 2019-11-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-24 | 2019-11-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-09-10 | 2019-10-24 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2019-08-22 | 2019-10-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-08-22 | 2019-10-14 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-22 | 2019-10-14 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2019-05-07 | 2019-06-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-05-07 | 2019-06-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-05-07 | 2019-06-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-07 | 2019-06-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-07 | 2019-06-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-30 | 2019-05-29 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-15 | 2019-04-12 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-03-15 | 2019-04-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-03-15 | 2019-04-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-15 | 2019-04-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-03-15 | 2019-04-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-15 | 2019-04-12 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is ne | Health | 2019-03-15 | 2019-04-12 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-03-15 | 2019-04-12 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-03-15 | 2019-04-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-10-31 | 2018-12-10 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-10-31 | 2018-12-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-10-31 | 2018-12-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-10-31 | 2018-12-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-10-31 | 2018-11-19 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2018-10-31 | 2018-11-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-31 | 2018-11-19 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-10-31 | 2018-11-19 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-10-31 | 2018-11-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-06-20 | 2018-07-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-06-20 | 2018-07-31 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is ne | Health | 2018-06-20 | 2018-07-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-06-20 | 2018-07-31 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-02-09 | 2018-05-17 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2018-02-09 | 2018-05-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-02-09 | 2018-05-17 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-02-09 | 2018-05-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-02-09 | 2018-05-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-02-09 | 2018-05-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-02-09 | 2018-05-17 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-02-09 | 2018-05-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-02-09 | 2018-05-17 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-02-09 | 2018-05-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-02-21 | 2018-05-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-02-21 | 2018-05-16 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2018-02-21 | 2018-05-16 | N |
| Be properly staffed | Fire Safety | 2018-02-21 | 2018-04-26 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-02-09 | 2018-04-11 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-02-09 | 2018-04-11 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-02-09 | 2018-04-11 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-02-09 | 2018-04-11 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-02-09 | 2018-04-11 | N |
| Respond appropriately to all alleged violations. | Health | 2018-02-09 | 2018-04-11 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2018-02-09 | 2018-04-11 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-02-09 | 2018-04-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-02-09 | 2018-04-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-02-09 | 2018-04-11 | N |
| Post nurse staffing information every day. | Health | 2018-02-09 | 2018-04-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-02-09 | 2018-04-11 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-02-09 | 2018-04-11 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-02-09 | 2018-04-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-09 | 2018-04-11 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-02-09 | 2018-04-11 | N |
| Keep all essential equipment working safely. | Health | 2018-02-09 | 2018-04-11 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-02-21 | 2018-03-31 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-02-21 | 2018-03-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-02-21 | 2018-03-31 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2018-02-21 | 2018-03-31 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-02-21 | 2018-03-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-02-21 | 2018-03-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-02-21 | 2018-03-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-02-21 | 2018-03-31 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2018-02-21 | 2018-03-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-02-21 | 2018-03-31 | N |
| Keep all essential equipment working safely. | Health | 2017-09-19 | 2017-10-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-05-01 | 2017-06-30 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-05-01 | 2017-06-30 | Y |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-05-01 | 2017-06-30 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-05-01 | 2017-06-30 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-05-01 | 2017-06-30 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-05-01 | 2017-06-20 | Y |
| Give the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances. | Health | 2017-05-01 | 2017-06-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-05-01 | 2017-06-20 | Y |
| Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility. | Health | 2017-05-01 | 2017-06-20 | Y |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2017-05-01 | 2017-06-14 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2017-01-04 | 2017-02-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-01-04 | 2017-02-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-01-04 | 2017-02-18 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2017-01-04 | 2017-02-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-01-04 | 2017-02-18 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2016-11-18 | 2017-01-06 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-11-18 | 2017-01-06 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-11-18 | 2017-01-06 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2016-11-18 | 2017-01-06 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-11-18 | 2017-01-06 | N |
| Provide or obtain dental services for each resident. | Health | 2016-11-18 | 2017-01-06 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-11-18 | 2017-01-06 | N |
| Make sure that a working call system is available in each resident's room or bathroom and bathing area. | Health | 2016-11-18 | 2017-01-06 | N |
