Oxford Rehabilitation & Health Care Center

Inspectors wroteBased on observation, record review, and interview the facility failed to appropriately monitor the effective use of a low temperature dish machine. Specifically, the facility failed to document the parts per million (PPM) of the sanitizing solution, to ensure effective sanitization.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure a comfortable environment on two floors where residents reside. Specifically, the facility failed to ensure that the residents' comfort was maintained and comfortable temperatures were present, resulting in residents wearing jackets, hats, gloves inside and throughout the day and night, even when extra blankets and hot beverages were available.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure for one resident #109, out of a total sample of 24 residents, that recommended services were implemented in accordance with the Pre-admission Screening and Resident Review (PASRR) Level II Evaluation Determination Summary. Specifically, Resident #109 was screened to meet PASRR criteria for SMI (serious mental illness) with recommended behavioral health services, individual psychotherapy.

Inspectors wroteBased on observation, record review and interview the facility failed for one Resident (#37), out of a total sample of 24 resident to provide standards of quality of care. Specifically, the facility failed to identify an alteration in Resident #37's skin resulting in a delay in providing treatment and monitoring to ensure it was not worsening.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to identify and eliminate all known and foreseeable accident hazards in the resident's environment for three Residents (#75, #9, and #112), out of 24 total sampled residents. Specifically,1 For Resident #75, the facility failed to ensure a safe, hazard free environment when Resident #76 had an electric space heater in his/her room. 2. For Resident #9, the facility failed to ensure a safe, hazard free environment when Resident #9 had a small electric space heater in his/her room. 3. For Resident #112 the facility failed to ensure a safe, hazard free environment when Resident #112 had a small electric space heater in his/her room.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure professional standards of practice for the care of a suprapubic urinary catheter (a tube placed through the suprapubic region into the bladder to drain urine) for one Resident (#51) out of a total sample of 24 residents. Specifically, the facility failed to ensure the size of Resident #51's catheter was the same size the physician ordered.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for two Residents (#40 and #7) out of sample of 24 residents. Specifically,1 For Resident #40 the facility staff failed to ensure a physician's order was obtained for the administration and liter flow rate of oxygen to be administered. 2. For Resident #7 the facility failed to ensure that nursing consistently administered oxygen in accordance with the physician's orders.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure one Resident (#11) was free from a significant medication error, out of a total sample of 24 residents. Specifically, for Resident #11, the facility failed to ensure nursing administered intravenous (IV) daptomycin (antibiotic medication) was administered to a resident with a diagnosis of bacteremia (blood infection).

Inspectors wroteBased on observation and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to ensure medications were dated once opened according to manufacturer's guidelines in one of three medication carts observed.

Inspectors wroteBased on observation and interview, the facility failed to properly dispose of garbage and refuse outside near the dumpster, potentially hindering pest management efforts.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) program identified and ensured continuous evaluation of care delivery systems and to prevent continued concerns that affect the quality of life of the residents on all resident care units. Specifically, the facility failed to ensure a Quality Assurance Improvement plan was established when sources of concern were reported related to the residents being cold.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one unit ([NAME]), out of four units and for one Resident (#109) residing on the [NAME] Unit. Specifically, the facility failed to implement Enhanced Barrier Precautions (EBP) when providing care on the [NAME] Unit:For Resident #109, the facility staff failed to wear Personal Protective Equipment (PPE) while providing high contact care for the Resident on EBP with a feeding tube.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessments for three residents (#3, #5 and #109), out of a total sample of 24 residents. Specifically:1. For Resident #3 the MDS nurse failed to code a high-risk medication accurately. 2. For Resident #5, the MDS nurse failed to include a fall sustained by Resident #5 on the most recent MDS and, 3. For Resident #109, the MDS nurse failed to document the use of a gastrostomy tube (a tube used for enteral nutrition) These failures resulted in inaccurate MDS assessments being transmitted to the Centers of Medicare and Medicaid Services.

Inspectors wroteBased on observation, record review and interview, the facility failed to protect one Resident (#92), from neglect, out of a total sample of 25 residents. Specifically, the facility neglected to schedule a follow-up appointment for over ten months when a physician's order was written for a Gastrointestinal Doctor consult to determine a possible colostomy (a surgical procedure that creates an opening (stoma) in the abdominal wall to divert stool from the colon directly into a bag or pouch) reversal procedure resulting in emotional distress.

Inspectors wroteBased on observation and interview, the facility failed to provide a homelike environment during dining on 4 of 4 units. Specifically, the facility failed to ensure resident meals were served on standard dining ware and cutlery and instead were served Styrofoam boxes and plastic cutlery due to the dish machine being broken for approximately the last three months.

Inspectors wroteBased on observation and interview, the facility failed to maintain kitchen equipment in safe operating condition. Specifically, the facility failed to ensure the dish machine was functioning properly and replace it with a new, functional dish machine.

Inspectors wroteBased on observations, interviews, and record reviews for two Residents, (#50 and #16), out of three residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. When one out of two nurses observed made three errors out of 28 opportunities resulting in a medication error rate of 10.71%. Specifically: 1.) For Resident #50, Nurse #1 administered Linzess (oral medication for constipation) after a meal when the medication was ordered to be administered 30 minutes before a meal. 2.) For Resident #16, Nurse #1 administered the incorrect dose (two sprays instead of one) of a nasal spray (Azelastine HCL, used for allergies) and Nurse #1 failed to administer the correct fiber medication (psyllium husk instead of calcium polycarbophil).

Inspectors wroteBased on observations and interviews, the facility failed to ensure drugs and biologicals were stored in accordance with acceptable professional standards of practice. Specifically, the facility failed to 1. Ensure a treatment room containing resident-specific creams, lotions and other biologicals was locked while unattended on the first floor unit and 2. Ensure medication carts were locked while unattended by staff on the first and second floor units.

Inspectors wroteBased on observation and interview, the facility failed to ensure a dignified dining experience for one Resident, (#52), out of a total sample of 25 residents. Specifically, the facility failed to ensure the needed assistance with a meal was provided resulting in a.) the Resident resorting to feeding him/herself with his/her hands and b. served the Resident in a Styrofoam dish with plastic utensils.

Inspectors wroteBased on interviews and record review, the facility failed to implement written policies and procedures for the investigation of allegations of abuse, protection of residents during investigations, reporting of allegations and investigative findings, and taking corrective actions to protect other residents from potential abuse for one Resident, (#55), out of a total sample of 25 residents.

Inspectors wroteBased on interviews and records reviewed, the facility failed to report an allegation of abuse to the State Agency for one Resident (#55) out of a total sample of 25 residents.

Inspectors wroteBased on observation and interview, the facility failed to implement the care plan for one Resident (#6) out of a total sample of 20 residents. Specifically, the facility failed to ensure that the call light was within reach of Resident #6 while he/she was in bed.

Inspectors wroteBased on observations, and interviews, the facility failed to ensure residents on the first-floor unit were provided with care in accordance with professional standards of practice. Specifically, two different surveyors at two different times observed Nurse #1 prepare and administer medications without referencing the medication administration record in the electronic health record.

Inspectors wroteBased on observation and interview, the facility failed to provide assistance with Activities of Daily Living (ADL) for one Resident, (#52), out of a total sample of 25 residents. Specifically, for Resident #52 the facility failed to provide assistance with feeding.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure interventions related to pressure injury healing were implemented for two Residents, (#5 and #39), out of a total of 25 sampled Residents. Specifically, the facility failed to ensure Resident #5 and Resident #39's air mattresses was on the correct setting.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care consistent with professional standards of practice for one Resident, (#39), out of a total sample of 25 residents. Specifically, the facility failed to ensure oxygen was administered at the correct setting.

Inspectors wroteBased on record review and interview, the facility failed to maintain accurate medical records for one Resident, (#86), out of 25 sampled residents. Specifically, for Resident #86 the facility failed to maintain accurate neurological flow sheets after two unwitnessed falls.

Inspectors wroteNOT CORRECTED Based on observations and interview, the facility failed to adhere to infection control practices and standards, increasing the risk of contamination and spread of infection for residents in the facility. Specifically, two different surveyors at different times during the day shift observed Nurse #1 touch pills directly with her ungloved hands during the medication pass.

Inspectors wroteBased on interview, observations and a review of invoices, the facility failed to ensure a homelike environment for two of two resident occupied floors. Specifically, the facility failed to ensure bedroom ceilings, walls, furniture, bathrooms and floors were undamaged and clean.

Inspectors wroteBased on interview and observation, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to: 1. Ensure its roof did not leak, which caused chronic widespread damage to bedroom and hallway ceiling tiles in resident care areas and 2. Ensure it had an effective pest control program.

Inspectors wroteBased on interview, observations and review of Pest Control Logs and the Pest Control contract, the facility failed to ensure an effective pest control program on two of two resident occupied floors.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure for five Residents (#7, #17, #23, #36 and #62) that care plans were implemented, out of a total sample of 36 residents. Specifically: 1. For Residents #7, #17, #23 and #62, the facility failed to provide supervision with meals, per the plan of care. 2. For Resident #36, the facility failed to ensure his/her heels were offloaded.

Inspectors wroteBased on interview and record review, the facility failed to ensure one Resident's (#105) grievance regarding missing personal items was addressed, out of a sample of 36 residents.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of sexual abuse to state officials for one Resident (#105) out of a total sample of 36 residents.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure enteral nutrition provided via a gastrostomy tube (a tube surgically inserted through the abdominal wall directly into the stomach with the purpose of delivering food, typically in the form of liquid formula) was provided according to professional standards. Specifically, the facility failed to ensure that Resident #112's enteral nutrition was administered within the physician-prescribed parameters resulting in a clinically significant and unintentional weight gain.

Inspectors wroteBased on interview, record review and observation for one resident (Resident #63) of a total of 36 sampled residents, the facility failed to implement medication orders and treatments for peripherally inserted central catheter (PICC) line sites. Specifically: the facility failed to document administration of the antibiotic ceftriaxone and saline flushes, assess the PICC line site, change and label the dressing, change the needless connector, change the tubing, or measure the external catheter length. The facility policy Central Venous Access Device Catheter Dressing Change dated January 2022, included but was not limited to: - Refer to the IV order form [Infusion Therapy Flow Sheet] for dressing change frequency. - Dressing changes will occur according to the IV order and when the dressing is compromised (drainage, moisture observed, loose, soiled). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dental services for one Resident (#105) out of a total sample of 36 residents. Specifically, the facility failed to facilitate the replacement of Resident #105's dentures.

Inspectors wroteBased on interview, record review and observation for two Residents (#63, #115) out of a total of 36 sampled residents, the facility failed to document medication orders and treatments for peripherally inserted central catheter (PICC) line sites. Specifically: 1. For Resident #63, the facility failed to document administration of the antibiotic ceftriaxone and saline flushes, assess the PICC line site, change and label the dressing, change the needless connector, change the tubing, or measure the external catheter length. 2. For Resident #115, the facility failed to document PICC line site assessment, dressing changes, changing needleless connectors, and measuring external catheter length. The facility policy Central Venous Access Device Catheter Dressing Change dated January 2022, included but was not limited to: [...]

Inspectors wroteBased on interviews and policy review, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) program that had a systematic analysis and action plan to rectify identified issues. Specifically, after implementing actions to manage environmental concerns in the facility which included pest control management, cleanliness in the facility and managing repairs needed in the facility, the facility failed to measure the success and track the performance to ensure improvements were sustained.

Inspectors wroteBased on observation, document review and interview, the facility failed to ensure staff adhered to infection control practices during a medication pass.

Inspectors wroteBased on observation and interview the facility failed to ensure the call device system was working in one bedroom located on the first floor (room [ROOM NUMBER]).