Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Oxford Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in food service operations, including unclean kitchen equipment, improper food storage with unlabeled and expired items, and inadequate staff hygiene such as lack of hair restraints. Staff failed to maintain safe food temperatures and used chipped and dirty plates during meal service. There was confusion among staff regarding cleaning responsibilities, leading to unsanitary conditions in nourishment areas.
The facility did not follow the planned menu for residents on renal, diabetic renal, mechanically altered, and pureed diets, serving unapproved substitutions such as sliced cucumbers instead of carrots and hamburger meat instead of baked chicken leg. These actions were due to delayed shipments, staff shortages, and lack of communication among dietary staff and the RD, affecting multiple residents requiring therapeutic and texture-modified diets.
A resident with multiple complex medical conditions and severely impaired cognition experienced a significant change in condition and was transferred to the hospital. Although the physician was notified and the transfer was carried out, the responsible party was not immediately informed due to unsuccessful contact attempts and competing emergencies. The responsible party was ultimately notified by the hospital rather than facility staff.
A resident's DPOA did not receive a timely refund of a deposit after the resident was discharged to another facility. The refund was delayed due to pending insurance claims and a mailing address error, with the facility failing to follow up and reissue the check as required by policy.
Two residents with chronic pain had significant quantities of their prescribed oxycodone go missing, with medication cards and controlled drug records unaccounted for. Staff discovered the discrepancies during routine administration and audits, and a nurse with access during the relevant shifts was identified but could not be contacted after suspension. The missing medications were not found, and the affected residents did not miss any doses due to alternative pain management and timely replacement.
A resident with cognitive impairment and chronic health conditions was not consistently or accurately assessed for smoking supervision needs, as required by facility policy. Nursing staff missed quarterly smoking assessments, and documentation was inconsistent regarding whether the resident required supervision while smoking. The resident was observed smoking independently without staff present, and staff interviews revealed confusion about the assessment process and documentation.
A resident admitted with diabetes and atrial fibrillation did not receive scheduled evening doses of insulin and Apixaban because a nurse entered the medication orders into the EMR with an incorrect start date, causing the medications to be scheduled for the following morning. The medications were available in the Pyxis system, but neither the transcribing nurse nor the direct care nurse verified or administered the evening doses.
A resident with severe cognitive impairment and mobility deficits was care-planned for bilateral fall mats at bedside due to fall risk, but repeated observations showed the mats were not in place. Interviews revealed that assigned nursing staff were unaware of this intervention, despite confirmation from the MDS Coordinator, DON, and Administrator that the mats were required by the care plan.
A resident with multiple chronic conditions was admitted and did not receive prescribed bedtime medications on the day of admission due to medication orders being entered into the EMR with a start date for the following day. Nursing staff did not verify or administer the scheduled medications, and the DON was unaware of the missed doses.
The facility failed to properly dispose of garbage and refuse, with dumpsters overflowing and debris scattered around. Despite efforts to remove trash bags, the area remained unclean. The Dietary Manager noted that the dietary staff were responsible for cleaning smaller dumpsters, while the larger rental dumpster was not emptied as scheduled.
The facility failed to secure and manage medications properly, with loose tablets, expired medications, and unsecured medication carts observed. Staff interviews confirmed these deficiencies, highlighting a lack of adherence to medication management protocols.
The facility failed to maintain cleanliness in the kitchen, with heavy grease buildup and dried food on appliances, and dust on vents. Staff interviews revealed a lack of adherence to cleaning protocols, with insufficient staffing cited as a reason for the oversight.
The facility failed to maintain clean and sanitary conditions in two resident rooms on the 500 hall. Observations revealed sticky floors, litter, overflowing trash, and improperly arranged furniture. The absence of the assigned housekeeper due to illness and inadequate weekend staffing contributed to the oversight. The Maintenance Director confirmed that furniture was not rearranged after a pest control treatment. The Administrator acknowledged the need for consistent staffing to ensure cleanliness.
A resident's dignity was compromised when a housekeeper spoke to him in a demeaning manner and used curse words regarding the cleanliness of his room. The incident was witnessed by another housekeeper, who reported it to the MDS Nurse. The resident, who was cognitively intact, confirmed the event but expressed no further concerns after discussing it with the Administrator. The offending housekeeper was removed from the facility to ensure the resident's safety.
The facility did not update the daily nurse staffing information for one day during the survey period. Observations showed the staffing sheet was outdated, and interviews indicated a lapse in the process involving the Scheduler, Administrator, and Staff Development Coordinator.
Deficient Food Service Sanitation, Storage, and Staff Hygiene
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food service operations, including failure to maintain cleanliness of kitchen equipment such as the double door oven, stove drip pan, steam table backsplash, and the rack under the steam table. These items were found with burnt food, oil stains, dust, dirt, and water stains. Bowls stored on the rack were also dirty. The Certified Dietary Manager (CDM) acknowledged that cleaning schedules were not adequately followed and that some equipment and utensils were not cleaned as required. Food storage practices were also deficient. In the walk-in freezer, raw chicken was stored in an open cardboard box alongside an opened bag of garlic bread, with neither item labeled. In the walk-in refrigerator, containers of food, sliced deli meats, and cheeses were found unlabelled and undated. Staff food was improperly stored in the same refrigerator as facility food. Additionally, nourishment refrigerators throughout the facility contained unlabeled and expired food items, standing water, and were not kept clean. There was confusion among staff regarding responsibility for cleaning and discarding expired food, with both dietary and nursing staff failing to ensure proper labeling, dating, and removal of expired items. Further deficiencies included dietary staff not wearing required hair restraints or facial hair coverings while handling food and dishes. During tray line observation, chipped and dirty plates were found in use, and cold food items such as tuna salad were not maintained at safe temperatures, exceeding the required 40 degrees Fahrenheit. These failures in food handling, storage, and sanitation practices were confirmed through staff interviews and direct observation.
Failure to Follow Planned Menus and Approved Substitutions for Therapeutic and Texture-Modified Diets
Penalty
Summary
The facility failed to follow the planned menu for residents on renal, diabetic renal, mechanically altered, and pureed diets during a lunch meal. Specifically, the planned menu indicated that residents on renal and diabetic renal diets were to receive carrots, but due to a delayed shipment, carrots were not available at the time of meal service. Instead, sliced cucumbers were served, although this substitution was not communicated or approved according to the facility's procedures. The Certified Dietary Manager (CDM) and Assistant Dietary Manager both confirmed that the menu was not followed and that there was confusion regarding appropriate substitutions, with the Registered Dietitian (RD) not being informed about the need for a substitution for carrots. Additionally, for residents on mechanically altered and pureed diets, the planned menu called for baked chicken leg (ground or pureed with gravy), but hamburger meat was prepared and served instead. The dietary staff responsible for meal preparation stated that they followed the menu and consistency sheets, but the Assistant Dietary Manager and CDM were unaware of why hamburger meat was used in place of chicken. The RD was also not informed that hamburger meat was served instead of the planned menu item. These failures affected 7 residents on renal diets, 3 residents on diabetic renal diets, 17 residents on mechanically altered diets, and 12 residents on pureed diets. The deficiencies were identified through tray line observation, record review, and staff interviews, which revealed a lack of communication, failure to follow the planned menu, and improper handling of menu substitutions for therapeutic and texture-modified diets.
Failure to Immediately Notify Responsible Party of Resident Hospital Transfer
Penalty
Summary
The facility failed to immediately notify the responsible party (RP) when a resident experienced a significant change in condition and was sent to the hospital. The resident, who had a history of nontraumatic intracerebral and intracranial hemorrhage, type 2 diabetes mellitus, dysphagia, dementia, and hemiplegia/hemiparesis, was noted to have severely impaired cognition. On the date of the incident, the resident was found to have an altered level of consciousness, was difficult to arouse, non-verbal, and had minimal response to stimuli. The physician was notified and ordered the resident to be sent to the hospital for evaluation. Although the House Nursing Supervisor attempted to call the RP to notify them of the transfer, no one answered, and it was unclear if a voicemail was left. The supervisor became occupied with another emergency and did not make further attempts to contact the RP that day. The following morning, the supervisor tried again and learned that the hospital had already notified the RP about the transfer the previous evening. The Director of Nursing confirmed that the RP should have been notified at the time of the transfer.
Failure to Timely Refund Resident Deposit After Discharge
Penalty
Summary
The facility failed to provide a timely refund of a deposit to a resident's Durable Power of Attorney (DPOA) following the resident's discharge. The resident, who initially paid privately for care, was discharged to another skilled nursing facility and was owed a refund of approximately $1,700. Despite the DPOA's repeated contact with the facility's Business Office Manager (BOM) after discharge, the refund was not issued within the required 30 days. The BOM stated that the delay was due to pending insurance claims, which were resolved several months after discharge, and a subsequent error in the mailing address that resulted in the refund check being returned. The BOM acknowledged that she had not requested a new refund check with the corrected address due to an oversight. Interviews with the Director of Office Services and the Administrator confirmed that facility policy required refunds to be provided within 30 days of discharge and after all insurance payments were received. The Director of Office Services was not aware of the returned check until months later and had not received updated address information to reissue the refund. The Administrator confirmed that the resident or their representative should have received the refund according to regulation, but this did not occur due to the facility's failure to follow up and correct the mailing issue.
Failure to Protect Residents from Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to protect residents from the misappropriation of controlled substance medications, specifically oxycodone, prescribed for pain management. Two residents with chronic pain and other significant medical conditions were affected. For one resident, a physician's order for oxycodone was received and the medication was delivered and documented as administered on several occasions. However, the controlled drug record, which should have documented each withdrawal of the medication, was missing, and a significant number of tablets could not be accounted for. For the second resident, multiple deliveries of oxycodone were documented, but the corresponding controlled drug records for these deliveries were also missing, and a large quantity of tablets was unaccounted for. The events leading to the deficiency included the discovery by nursing staff that the bubble pack cards containing oxycodone and their corresponding controlled drug records were missing from the medication carts. Staff interviews confirmed that the medications were present and administered as ordered on previous shifts, but were later found to be missing. The facility's investigation identified a specific nurse who had access to the medication carts during the relevant shifts and was subsequently unable to be contacted after being suspended pending investigation. The missing medications were not found despite comprehensive searches and audits of medication carts and records. The affected residents did not report missing any doses of their pain medication, as alternative pain management was provided and replacement medications were obtained. The facility's records and staff interviews confirmed that the missing medications were as-needed (PRN) and had not been requested by the residents prior to the discovery of the discrepancy. The total number of missing oxycodone tablets between the two residents was determined to be 91, with no documentation or explanation for their disappearance.
Failure to Complete Accurate and Timely Smoking Assessments
Penalty
Summary
The facility failed to ensure that smoking assessments were accurate and completed quarterly for a resident with a history of Parkinson's disease and chronic obstructive pulmonary disease. Upon admission, the resident was not using tobacco and was assessed as severely cognitively impaired. However, subsequent assessments and interviews revealed inconsistencies in the documentation and completion of smoking assessments. The resident began smoking after admission, and the assessments regarding his need for supervision while smoking were not consistently or accurately completed as required by facility policy. Nurse staff responsible for conducting smoking assessments admitted to missing some assessments and acknowledged confusion regarding the assessment process and documentation. The resident's smoking status and need for supervision were inconsistently recorded, with one assessment indicating a need for supervision, which was later struck through and replaced with an assessment stating the resident could smoke independently. The Director of Nursing confirmed that a quarterly assessment was missed and that the process for notifying nurses of due assessments was in place, but not followed in this instance. Observations showed the resident smoking independently in the designated area without staff supervision, and interviews with staff and the resident confirmed that he sometimes kept his own smoking materials, while at other times, they were stored by nursing staff. The facility's list of smokers did not consistently include the resident, and there was a lack of clarity and accuracy in the documentation and oversight of the resident's smoking status and supervision needs.
Failure to Administer Scheduled Admission Medications Due to EMR Entry Error
Penalty
Summary
A deficiency occurred when a newly admitted resident with diagnoses including type 2 diabetes mellitus with chronic foot ulcer and atrial fibrillation did not receive scheduled evening doses of Lantus insulin and Apixaban on the day of admission. The nurse responsible for transcribing the admission orders entered the medications into the electronic medical record (EMR) but did not adjust the automatically generated start date and time, resulting in the medications being scheduled to begin the following morning. The nurse did not check the Pyxis system to verify if the medications were available for administration that evening, nor did she review whether any medications were due that night. As a result, the resident did not receive the prescribed 8:00 PM and 9:00 PM doses on the day of admission, despite the medications being available in the Pyxis system. The direct care nurse for the evening shift was unaware that the resident had scheduled medications due that night, as the EMR reflected a start date of the following day. The Director of Nursing confirmed that the transcribing nurse should have verified the start date and time for the medications and ensured administration per physician orders. The physician interviewed stated that medications should be administered on the date of admission if scheduled, and although there was potential for negative outcomes, none were documented as a result of the missed doses.
Failure to Implement Care Planned Fall Safety Interventions
Penalty
Summary
The facility failed to implement care planned interventions for fall safety for a resident with hemiplegia and hemiparesis following a stroke, who was severely cognitively impaired and required total assistance for activities of daily living. The resident's care plan identified a risk for falls related to muscle weakness and reduced mobility, specifying the use of bilateral fall mats at the bedside as an intervention. However, during multiple observations, the resident was found lying in bed without fall mats present on either side. Interviews with nursing staff, including a nursing assistant and a nurse assigned to the resident, revealed that they were not aware of the care plan requirement for bilateral floor mats for fall injury prevention. The MDS Coordinator confirmed that the resident was actively care-planned for the use of bilateral floor mats, and both the Director of Nursing and the Administrator acknowledged that staff should have followed the care plan and provided the mats as indicated.
Failure to Administer Admission Medications per Physician Orders
Penalty
Summary
The facility failed to ensure that medication orders for a newly admitted resident were accurately entered into the electronic medical record (EMR) and administered according to physician orders. Upon admission, the resident had multiple diagnoses including Type 2 diabetes mellitus with chronic foot ulcer, hypertension, atrial fibrillation, and congestive heart failure. Physician orders specified several medications to be administered at bedtime on the day of admission. However, the medications were entered into the EMR with a start date for the following day, resulting in no medications being administered on the evening of admission. Nurse interviews revealed that the nurse responsible for entering the orders did not verify if any medications were due that evening and did not check the medication dispensing system for availability. The direct care nurse was unaware that scheduled medications should have been administered that night due to the EMR start date. The Director of Nursing was not aware of the missed doses, and the physician confirmed that medications should have been given as ordered on the admission date. As a result, the resident did not receive any of the prescribed medications on the evening of admission.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during an initial tour on June 30, 2024. Four dumpsters located near a wooded area at the back of the facility were found with large amounts of trash bags overflowing from the tops, and loose paper products, boxes, and food products scattered on the ground and surrounding areas. A follow-up observation on July 2, 2024, revealed that while the trash bags had been removed, the surrounding area had not been thoroughly cleaned, with paper and food products still present on the ground. The Dietary Manager indicated that the dietary staff were responsible for cleaning the three smaller dumpsters daily, and the larger rental dumpster was scheduled to be emptied on June 28, 2024, but was not, despite several calls made by the administrator and maintenance director to the rental company.
Medication Management Deficiencies
Penalty
Summary
The facility failed to properly secure and manage medications across multiple areas, as observed during a survey. On the 400 hall medication cart, thirty-two loose and unidentifiable tablets were found, along with multiple lidocaine vials lacking security caps and opened-on dates. Additionally, a Latanoprost eye drop was found to be expired, having been opened on 4/12/24 and not discarded by the expiration date of 5/22/24. Interviews with staff, including a medication aide and the interim Director of Nursing (DON), confirmed that these medications should have been marked when opened and discarded when expired. In the 500 hall medication room, an acetaminophen suppository with an expiration date of 12/2020 and a COVID-19 vaccine with an expiration date of 4/24/2024 were found. Nurse #3 acknowledged that expired medications should be discarded. Additionally, on the 100 hall, a medication cart was left unattended with two tablets of Renvela on top, unsecured, while Nurse #4 administered medication to another resident. The nurse admitted the oversight and the Administrator confirmed that all medications should be secured or properly discarded.
Facility Fails to Maintain Cleanliness in Kitchen Areas
Penalty
Summary
The facility failed to maintain cleanliness in the food preparation and service areas, as observed during a kitchen tour. The stove burners, ovens, and fryer were found with heavy grease buildup, dried food, and liquid spills. The floor beneath these appliances was littered with dried food, grease puddles, and trash. Additionally, the plate warmers and steam table contained dried food particles and spills, and the ceiling vents and air conditioning units were covered in black dust and debris, potentially contaminating food preparation surfaces. Interviews with the kitchen staff revealed a lack of adherence to cleaning protocols. The Cook/Dietary Aide was unaware of the last cleaning of the plate and base warmers and mentioned insufficient staffing to manage both cooking and cleaning tasks. The Dietary Manager and Kitchen Supervisor admitted that the kitchen equipment and areas had not been cleaned according to the checklist, and the Maintenance Director acknowledged that the ceiling vents and fans had not been cleaned for several months, attributing it to an oversight.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in two resident rooms on the 500 hall, as observed during a survey. In one room, the floor was sticky with spilled food particles and littered with paper, and the resident reported that housekeeping had not cleaned the room as expected. In another room, the floor was also sticky, with crumpled wipes packets and paper on the floor, an overflowing trash can, and a biohazard bin filled with personal protective equipment. The furniture was improperly arranged, with a couch placed upside down, and the side table was dusty with visible stains. Interviews with housekeeping staff revealed that the assigned housekeeper for the 500 hallway was absent due to illness, and a floor tech was covering the duties. The floor tech admitted to starting cleaning on the 400 hallway and did not reach the 500 hallway until later, resulting in incomplete cleaning. He acknowledged the issues in the rooms but assumed maintenance was responsible for the furniture arrangement. The Maintenance Director confirmed that the furniture was not rearranged after a pest control treatment for bedbugs, which had occurred a few days prior. The Housekeeping Manager noted that there were fewer staff on weekends, which contributed to the oversight. The Administrator acknowledged that the 500 hallway required more frequent cleaning due to the residents' varying acuity levels and emphasized that the facility should maintain consistent staffing levels throughout the week. The deficiency was attributed to inadequate staffing and communication, leading to unclean and disorganized resident rooms.
Resident Dignity Compromised by Housekeeper's Inappropriate Conduct
Penalty
Summary
The facility failed to maintain a resident's dignity when a housekeeper spoke to a resident in a demeaning manner and used curse words. This incident involved a cognitively intact resident who was admitted to the facility on an unspecified date. The event was witnessed by another housekeeper who reported that the offending housekeeper cursed at the resident regarding the cleanliness of his room. The witness immediately reported the incident to the MDS Nurse and provided a written statement. The resident confirmed the incident, stating that he had not experienced such behavior before or since and had no further concerns after discussing it with the Administrator. The incident was reported to have occurred in the presence of the resident's roommate, who did not recall the event. The MDS Nurse confirmed that the offending housekeeper had left the building before she arrived and that the incident was reported to her by the witness. The Administrator also confirmed that the housekeeper was removed from the facility to ensure the resident's safety. Despite the incident, the resident expressed that he was not afraid and had not seen the staff member since.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information for one of the four days during the survey period. On 6/30/24, during the initial tour and multiple observations throughout the day, it was noted that the daily nurse staffing sheet posted near the facility lobby was dated 6/28/24, indicating it had not been updated to reflect the current date, census, and staffing information. Interviews revealed that the Scheduler was responsible for completing the staffing information for the week and provided these forms to the Administrator, who was responsible for posting the information daily. The Administrator stated that the Staff Development Coordinator was tasked with ensuring the daily nurse staffing sheet was accurately completed and posted in the lobby during the weekend, while the Administrator oversaw the process to ensure visibility for residents and visitors. The Staff Development Coordinator was unavailable for an interview.
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What surveyors actually found near you
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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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Nursing homes near Oxford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brantwood Nh & Retirement Center | 0.2 mi | ★★★★★ | 2 | 0 |
| Senior Citizens Home | 8.1 mi | ★★★★★ | 3 | 0 |
| Kerr Lake Nursing And Rehabilitation Center | 10.1 mi | ★★★★★ | 2 | 0 |
| Camellia Gardens Center For Nursing And Rehab | 10.2 mi | ★★★★★ | 7 | 1 |
| Clarksville Health & Rehab Center | 20.4 mi | ★★★★★ | 0 | 0 |
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