Oxford Nursing Home

Inspectors wroteBased on observation, interviews, and record review conducted during an Abbreviated Survey (664597 and 664596), the facility did not ensure that an alleged violation 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 or 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). This was evident for 2 (Resident #1 and Resident #2) out of 4 residents sampled for abuse. [...]

Inspectors wroteNumber of residents sampled: 1 Number of residents cited: 1 Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was evident for 1 (Resident #44) of 1 resident reviewed for Activities out of 38 sampled residents. Specifically, Resident #44 was not provided with activities that met their interests and cultural preferences.

Inspectors wroteBased on record review and staff interviews, during the Recertification survey, the facility did not ensure Minimum Data Set (MDS) 3.0 comprehensive and quarterly assessments were submitted and transmitted into the Quality Improvement Evaluation System Assessment Submission and Processing system in a timely manner. Specifically, admission, annual, and quarterly assessments were not submitted and transmitted within 14 calendar days after the assessments were completed. This was evident for 43 of 54 residents reviewed for the Resident Assessment facility task.

Inspectors wroteBased on observation, interviews, and record review conducted during a Recertification Survey from 9/20/2023 to 9/26/2023, the facility did not ensure baseline care plans (BCP) were completed timely and residents and their representatives were provided with a written summary of the BCP. This was evident for 3 of 38 total sampled residents. Specifically, 1) Resident #165 and their designated representative did not receive a copy of the BCP, 2) The BCP for Resident #447 was not completed timely and the resident and their designated representative did not receive a copy of the BCP, and 3) the BCP for Resident #171 was not completed within 48 hours of admission and a copy was not provided to the resident and their representative.

Inspectors wroteBased on observation, interviews, and record review conducted during the recertification survey from [DATE] to [DATE], the facility did not ensure drugs and biologicals were labeled and stored in locked compartments. This was evident for 3 (1st, 2nd, and 4th Floors) of 5 floors. Specifically, 1) intravenous antibiotic medication for reconstitution was not stored in a locked compartment on the 2nd Floor, 2) prescribed eye drops were observed unlabeled and undated on a medication cart on the 1st Floor, and 3) blister pack medications were observed stored behind nursing station accessible to the public on the 4th floor.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey conducted on 09/20/2023 through 09/26/2023, the facility did not facilitate the inclusion of the resident and the resident's representative in the comprehensive care planning (CCP) process. This was evident for 1 of 38 total sampled residents. Specifically, Resident #10's Health Care Proxy (HCP) was not invited to attend the resident's scheduled CCP meeting.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 09/20/2023 to 09/26/2023, the facility did not ensure menus were followed. This was evident for 1 (Resident #28) of 38 total sampled residents. Specifically, Resident #28 did not receive lunch menu items that were listed on their tray ticket (TT) including melon, pork chop with gravy, grilled cheese sandwich, chicken salad, tossed salad with ¾ cup dressing, red skin potatoes, 1 slice Italian bread, 4-ounce peaches, and 1 package saltine crackers.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 9/20/2023 to 9/26/2023, the facility did not ensure infection control practices were maintained. This was evident for 1 (2nd Floor) of 6 Units observed for dining. Specifically, the Certified Nursing Assistant (CNA) on the 2nd Floor did not perform hand hygiene between serving residents their meal trays.

Inspectors wroteBased on record review and staff interviews conducted during a recertification /complaint survey (NY00321529), The facility failed to ensure that an alleged violation involving resident to resident physical abuse was reported within a timely manner to the New York State Department of Health (NYSDOH). This was evident for 1 of 38 total sampled residents. Specifically, a resident-to-resident altercation that took place on 07/27/2023 was reported to the NYSDOH on 8/07/2023.

Inspectors wroteBased on observations, records review and staff interviews during the Recertification Survey, the facility did not ensure residents' personal medical information was kept confidential. Specifically, a notice which documented room numbers, type of precaution, and type of infection was observed posted throughout the facility. This was evident for 4 of 4 residents who were on Transmission Based Precautions. (Residents # 390, #133, #690, & 391)

Inspectors wroteBased on observations, record reviews, and interviews conducted during the recertification survey, the facility did not ensure that necessary housekeeping services were provided to maintain a safe, clean, comfortable, and homelike environment. Specifically, a corroded radiator cover, unpainted areas, mis-matched paint and water damage on the walls were observed in residents' rooms. This was evident in multiple rooms on 3 of 6 units. (Units 1, 2 & 3)

Inspectors wroteBased on record review, interviews and observations conducted during the recertification survey, the facility did not ensure that resident is free from physical restraints imposed for discipline or staff convenience and not required to treat the resident's medical symptoms. This was evident for 3 of 3 residents reviewed for Physical Restraints out of total sample of 38 residents (Residents #157, #35, and #110)

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey, the facility did not ensure that each resident and resident representative was involved in developing the care plan and making decisions about their care. Specifically, the facility did not ensure that residents and resident representatives were afforded the opportunity to participate in the Comprehensive Care Plan (CCP) meeting. This was evident for 4 out of 6 residents reviewed for Participation in Care Planning. (Resident #52, #67, #22 and #143).

Inspectors wroteBased on observation and staff interviews conducted during the recertification survey, the facility did not ensure that food was stored and prepared in accordance with professional standards for food service safety. Specifically, potentially hazardous cold foods were not maintained at the proper temperature (at or below 41 degrees Fahrenheit). This was observed during the Kitchen Observation facility task.

Inspectors wroteBased on observations, record review, and staff interviews conducted during the recertification survey, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1). blood pressure (BP) cuffs were not cleaned/disinfected after use between residents, 2). a housekeeping staff did not properly store and transport garbage while on the unit, and 3). a housekeeping staff did not don the required Personal Protective Equipment (PPE) upon entering a room where transmission-based precautions were in place. This was evident during the Infection Control Tasks on 4 of 6 units. (Units 3, 4, 2 & 5)

Inspectors wroteBased on observation and interview conducted during a recertification survey, the facility did not ensure that a safe, functional, sanitary, and comfortable environment is provided for staff and public. Specifically, the staff bathrooms and a resident bathroom were not maintained in good repair. This was observed on 3 of 6 resident units. (Unit 2, Unit 3 & Unit 4)

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification survey, the facility did not ensure it maintained an effective pest control program so that the facility is free of pests and rodents. Specifically, (1). One live rodent was noted in the dining area in the basement, and (2) one live brown colored roach about half an inch in length was noted in the nurse's station on the 5th Floor. This was evident on 1 of 6 units. (5th Floor)

Inspectors wroteBased on observations, record review, and interviews conducted during a recertification survey the facility did not ensure that based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident was provided. Specifically, the facility did not ensure that services were provided to a resident who required one to one (1:1) activities. This is evident for 1 of 5 residents reviewed for Activities out of the sample of 38 residents. (Resident #44)

Inspectors wroteBased on observation, record review and staff interview conducted during the recertification survey, the facility did not ensure timely identification and removal of expired medications from current medication supply. Specifically, expired medications were observed in the medication storage room. This was evident during the Medication Storage Task (Medication Storage Room/Nursing Office)

Inspectors wroteBased on observations and staff interviews conducted during a recertification survey, the facility did not ensure that all medications and biologicals were stored and labeled properly. Specifically, medications were not labelled properly. This was evident during observations conducted for the Medication Storage Task. (3rd floor)

Inspectors wroteBased on interview and record review conducted during the recertification survey, the facility did not ensure each resident received food that accommodated resident allergies, intolerance, and preferences. Specifically, residents' food preferences were not honored. This was evident for 2 of 7 residents reviewed for Food out of a sample of 38 residents. (Resident # 22 and Resident # 144)