Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oxley Park Health And Rehabilitation during CMS and state inspections, most recent first.
Improper food storage and unsanitary kitchen equipment were observed in the dietary dept. Expired food items were found in the freezer and pantry, leftover hamburgers were left unlabeled and undated, shredded lettuce was unsealed and unlabeled, and cucumbers had a white film. Two basket deep fryers and a can opener also had blackened grease and debris. The CDM confirmed the findings, and the RD and Admin stated that food should be properly labeled, stored, dated, and discarded.
Failure to Perform Hand Hygiene During Medication Administration: CMAs did not perform required hand hygiene while giving meds and treatments to three residents. One CMA administered oral meds, an inhaler, and insulin to a resident with severe cognitive impairment without hand hygiene and without gloves for the insulin injection; she also failed to sanitize before preparing meds for another resident. Another CMA did not clean her hands before setup or room entry, used gloves for eye drops, then removed them and continued care before using sanitizer only when exiting. The facility policy stated hand hygiene is the single most important means of preventing infection spread.
Improper Preparation of Pureed Diets: Staff failed to properly prepare puree meals for two residents on therapeutic puree diets. A Dietary Aide used too much thickener, then added unmeasured water, and stated staff did not use standardized recipes and prepared puree meals from memory. A resident with dysphagia, TBI, and GERD was observed receiving a meal that was not pureed and had a lumpy consistency, which the DON, Administrator, and RD confirmed did not meet puree standards.
The facility failed to discard expired food in the walk-in cooler and did not ensure dietary staff wore proper hair restraints in the kitchen, potentially affecting 86 of 92 residents on an oral diet. Expired lettuce and rotting potatoes were found, and two dietary aides had hairnets that only partially covered their hair. The Dietary Manager and corporate Registered Dietician confirmed the deficiencies.
A resident with chronic obstructive pulmonary disease and other conditions was prescribed oxygen at 2 LPM, but was observed receiving 3 LPM. The DON confirmed the discrepancy, and the facility's policy requires care plans to be followed and updated as needed. The MDS Coordinator emphasized the expectation for staff to adhere to care plans.
A facility failed to revise a care plan for a resident receiving O2 therapy. The resident had a physician's order for O2 at 2 LPM, but was observed receiving 3 LPM. The resident was known to adjust the O2 rate independently, but this was not reflected in the care plan. The facility's policy requires care plans to be updated based on changing needs, which was not done in this case.
A resident with chronic health conditions was observed receiving oxygen therapy at 3 LPM, contrary to the physician's order of 2 LPM. The DON confirmed the discrepancy and acknowledged the expectation for staff to adhere to physician orders, highlighting a failure in following prescribed O2 administration.
The facility failed to ensure proper donning and doffing of PPE for Droplet Precautions in two rooms. A CNA was observed leaving a droplet precaution room with PPE on and doffing it outside the room, contrary to protocol. This was confirmed by the DON and Infection Preventionist. The facility also lacked a policy on proper PPE procedures, contributing to the deficiency.
Improper Food Storage and Unsanitary Kitchen Equipment
Penalty
Summary
Improper food storage and unsanitary food preparation conditions were identified in the dietary department based on observations, staff interviews, and review of the facility’s Food and Supply Storage policy. The policy stated that foods past their use-by, sell-by, best-by, or enjoy-by dates should be discarded and that unused portions and open packages should be covered, labeled, and dated. During observation with the Certified Dietary Manager, the walk-in freezer contained a box of frozen pie dough rounds with an expiration date of 12/23/2025 and a box of macaroons with an expiration date of 02/04/2026. The walk-in refrigerator contained a white Styrofoam plate with leftover hamburgers that were not labeled or dated, a bag of shredded lettuce with brown leaves that was unsealed and without a label, and a box of cucumbers covered with a white film and an expiration date of 02/27/2026. Additional findings in the dry pantry included a box of graham crackers with an expiration date of 03/02/2026 and a box of sweet chocolate chips with an expiration date of 12/16/2025. Two basket deep fryers contained blackened, used grease, a greasy black substance on the top of the fryer, and crumbs on both sides, and the can opener contained a greasy black substance. The Certified Dietary Manager confirmed the concerns and stated dietary staff needed re-education regarding proper labeling, dating, and discarding of food items. The Registered Dietitian and Administrator both stated their expectation that staff properly label, store, date, and discard expired food.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when certified medical assistants did not perform proper hand hygiene while administering medications to three sampled residents. Review of the facility’s Hand Hygiene policy stated that hand hygiene is the single most important means of preventing the spread of infection and that gloves do not replace hand washing. The policy also directed staff to use alcohol-based hand rub or wash hands before touching a patient, before aseptic tasks, after touching a patient or the patient’s immediate environment, after contact with contaminated surfaces, and immediately after glove removal. R8 had diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms and Type 2 diabetes mellitus with hyperglycemia, and a BIMS score of 1 indicating severe cognitive impairment. During observation, CMA EE did not perform hand hygiene before medication setup, did not sanitize hands upon entering the room, and administered oral medications, an inhaler, and insulin without hand hygiene; she also did not wear gloves when giving insulin. After leaving R8’s room, CMA EE did not perform hand hygiene before preparing medications for another resident. CMA EE later stated she realized after the fact that she had not worn gloves when administering insulin and confirmed she did not perform hand hygiene during medication administration. R63 had diagnoses including Type 2 diabetes mellitus with hyperglycemia, gait and mobility abnormalities, and chronic kidney disease stage 4, with a BIMS score of 6 indicating severe cognitive impairment. CMA EE did not perform hand hygiene before setting up or administering medications to R63. She donned gloves to apply a lidocaine patch but did not sanitize her hands before putting on gloves, and after removing the gloves she did not perform hand hygiene. R91 had diagnoses including dementia with anxiety, hyperlipidemia, anxiety disorder, alcohol abuse with alcohol-induced disorder, depression, hypertension, constipation, GERD, and insomnia, with a BIMS score of 11 indicating moderate cognitive impairment. CMA DD did not perform hand hygiene before medication setup or upon entering the room, donned gloves to administer eye drops, removed the gloves, applied a blood pressure cuff, administered oral medications, and used hand sanitizer only when exiting the room. CMA DD stated she had been employed for about two years and confirmed she did not perform hand hygiene as required.
Improper Preparation of Pureed Diets
Penalty
Summary
The facility failed to ensure pureed therapeutic diets were properly prepared for two sampled residents receiving a puree diet. During observation of pureed chopped steak preparation, the Dietary Aide used an excessive amount of thickener that overflowed the measuring spoon, and the consistency was described by the CDM and RD as too thick. The aide then added an unmeasured amount of water on two occasions to obtain the proper modified consistency. The aide stated that neither she nor other staff used a recipe when preparing pureed meals and that she prepared pureed meals from memory rather than using a standardized recipe. The CDM and RD both stated that staff were expected to use standardized recipes, and the RD reported she had never observed the dietary staff complete the puree process until that day. R58 had diagnoses including dysphagia, diffuse traumatic brain injury with loss of consciousness, and GERD, and the MDS indicated moderate cognitive impairment and a mechanically altered diet requiring puree food. R58’s physician order specified a puree diet. On observation, R58 was served a meal that was not pureed and included pork chops, vegetables, bread, and gravy with a lumpy consistency. The DON and Administrator confirmed the meal was not of pureed consistency, and the RD later reviewed a photo of the meal and confirmed the plated food items did not meet the standard of a pureed food item.
Deficiencies in Food Storage and Personal Hygiene in Kitchen
Penalty
Summary
The facility failed to adhere to its policies regarding food storage and personal hygiene in the kitchen, which had the potential to affect 86 of 92 residents receiving an oral diet. During a tour of the kitchen, it was observed that the walk-in cooler contained expired food items, including a bag of lettuce and a box of potatoes, some of which were rotting. The Dietary Manager confirmed the presence of these expired items and acknowledged that it was the responsibility of her and her staff to label, date, and discard expired items appropriately. Additionally, the facility did not ensure that dietary staff wore proper hair restraints while in the food preparation area. Observations revealed that two dietary aides had hairnets that only partially covered their hair, leaving parts of their hair exposed. The corporate Registered Dietician and the Dietary Manager confirmed that all kitchen staff should have their entire head of hair covered while handling and serving food, and they addressed the issue with the staff members involved.
Failure to Follow Oxygen Care Plan for Resident
Penalty
Summary
The facility failed to adhere to the care plan for a resident, identified as R184, specifically regarding the prescribed rate of oxygen. The resident had a medical history that included chronic obstructive pulmonary disease, atrial fibrillation, heart failure, and a dependence on supplemental oxygen. The physician's order, dated January 10, 2025, specified that the resident should receive oxygen via nasal cannula at a rate of 2 liters per minute every 8 hours. However, during an observation on January 30, 2025, the resident was found to be receiving oxygen at a rate of 3 liters per minute. The Director of Nursing confirmed the discrepancy between the observed oxygen rate and the physician's order. The facility's policy requires that each patient's care plan be reviewed and updated based on ongoing clinical assessments and changes in the patient's condition. Despite this policy, the staff did not follow the care plan as prescribed, leading to the deficiency. The Minimum Data Set Coordinator also expressed that staff are expected to adhere to the care plan, highlighting a lapse in following established procedures.
Failure to Revise Care Plan for Oxygen Use
Penalty
Summary
The facility failed to revise a care plan related to oxygen (O2) use for a resident receiving O2 therapy. The resident, identified as R184, had a physician's order for O2 via nasal cannula at 2 liters per minute (LPM) every 8 hours. However, during an observation, the Director of Nursing (DON) found the resident receiving O2 at a rate of 3 LPM. The DON confirmed that the resident was known to adjust the O2 rate independently, but this behavior was not reflected in the care plan. The care plan, initiated on the same date as the physician's order, did not include interventions for monitoring or addressing the resident's tendency to change the O2 flow rate. The facility's policy requires that care plans be reviewed and revised based on changing needs and interventions. Despite this, the care plan for R184 was not updated to include the resident's behavior of adjusting the O2 rate, nor were there any interventions added to address this issue. The DON acknowledged that staff should be checking the O2 more frequently due to the resident's known behavior. The Minimum Data Set (MDS) Coordinator confirmed that the care plan should be individualized to fit the resident's ongoing needs, which was not done in this case.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to ensure that the physician's order for oxygen (O2) administration was followed for a resident. The resident, who had diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, heart failure, and dependence on supplemental O2, had a physician's order for O2 via nasal cannula at 2 liters per minute (LPM) every 8 hours. However, observations on multiple occasions revealed the resident receiving O2 at 3 LPM instead of the ordered 2 LPM. The Director of Nursing (DON) confirmed the discrepancy between the physician's order and the actual O2 administration, acknowledging that the expectation was for staff to follow physician orders. This failure had the potential to place the resident at risk for medical complications related to O2 not being administered as ordered.
Improper PPE Doffing for Droplet Precautions
Penalty
Summary
The facility failed to ensure proper donning and doffing of Personal Protective Equipment (PPE) for Droplet Precautions in two of twelve rooms, as observed during a survey. A Certified Nurse Assistant (CNA) was seen leaving a droplet precaution room while still wearing gloves, a face shield, a mask, and a gown, and subsequently doffing the PPE outside the room instead of inside, as required. This practice was confirmed through interviews with the CNA, the Director of Nursing (DON), and the Infection Preventionist, who all acknowledged the improper procedure. Additionally, the facility lacked a specific policy addressing the correct procedures for donning and doffing PPE, which contributed to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Oaks - Bethany Skilled Nursing, The | 2.2 mi | ★★★★★ | 12 | 0 |
| Meadows Park Health And Rehabilitation | 5.5 mi | ★★★★★ | 0 | 0 |
| Tattnall Healthcare Center | 16 mi | ★★★★★ | 10 | 0 |
| Treutlen County Health And Rehabilitation | 18.7 mi | ★★★★★ | 3 | 0 |
| Glenwood Health And Rehabilitation | 19.7 mi | ★★★★★ | 22 | 0 |
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