Above 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 Oxford Health Center during CMS and state inspections, most recent first.
The facility failed to follow its infection surveillance and outbreak policies for residents with GI symptoms. Policy required nursing staff to report residents with multiple loose stools or other infection indicators so the DON or IC coordinator could enter them on a surveillance line list and monitor for trends, and to initiate an outbreak investigation when an emerging infectious disease was suspected. Several residents on one unit with more than one loose bowel movement in 24 hours were entered on an outbreak line list, but two additional residents with documented multiple loose stools and vomiting were not added. The IC nurse, who worked part-time and had the line list handed off from a prior DON, could not explain the omission of these residents and confirmed that no investigation was completed to determine the source of the GI symptoms.
A resident with Alzheimer's disease, osteoarthritis, and a history of falls sustained a skin tear during a transfer using a stand-up lift when staff, unaware of her updated transfer requirements, did not provide the necessary assistance and cues. The assignment sheet used by CNAs was not updated to reflect her need for a two-person transfer and specific precautions, resulting in inadequate supervision and an accident.
The facility did not maintain the smoke resistance of smoke barrier walls, as observed in the basement Linen Storage Room where two unprotected penetrations were found after pipe removal. This issue, confirmed by the Maintenance Manager, affected two of the 14 smoke compartments, compromising the smoke barrier's integrity.
The facility did not maintain the fire resistance of common walls, affecting one smoke compartment. Observations revealed four unprotected penetrations in the wall separating the 01 and 02 Components, located above the ceiling and doors. Three penetrations were around wires, and one was empty. The Maintenance Manager confirmed these findings.
The facility did not maintain the fire resistance of an exit stairtower enclosure, affecting one smoke compartment. The fire exit hardware on the 1st floor Rosewood East Stairwell door was missing an end cap, compromising its fire resistance. This was confirmed by the Maintenance Manager.
The facility failed to maintain smoke resistance in a hazardous area enclosure, affecting one of 14 smoke compartments. The basement door to the Maintenance Storage Room, over 100 square feet, lacked an automatic closure. This was confirmed by the Maintenance Manager.
A portable fire extinguisher in the basement Elevator Machine Room was found unsecured on the floor, having been removed from its wall bracket. This was confirmed by the Maintenance Manager during a survey.
The facility failed to monitor the use of surge suppressors and extension cords, leading to a deficiency. Observations revealed a surge suppressor powering an extension cord for communications equipment in the basement and a receptacle multiplying power tap supplying a surge suppressor in the Chapelwood Communications Closet. These setups were confirmed by the Maintenance Manager.
The facility failed to ensure accurate MDS assessments for three residents, with errors in documenting insulin administration and pressure ulcers. Staff interviews confirmed discrepancies between MDS entries and clinical records, highlighting inaccuracies in resident status documentation.
The facility failed to ensure timely responses to call bells on two floors, with an average response time of 28.07 minutes and some extending up to 111.05 minutes. Residents and a family member reported concerns about prolonged waits, with one resident experiencing delays of 45 to over 60 minutes. The NHA confirmed these findings, noting that response times over 40 minutes are investigated.
Failure to Accurately Track and Investigate GI Symptoms Under Infection Control Program
Penalty
Summary
The facility failed to implement its infection prevention and control surveillance policies for residents with gastrointestinal (GI) symptoms. The written policy "Surveillance for Infection/Infectious Disease" required nursing staff to notify the charge nurse when residents had a temperature of 100°F or greater, two or more loose watery stools in 24 hours, skin inflammation or purulent drainage, or a hospital transfer due to infection, and required the DON or Infection Control (IC) Coordinator to enter such data on a Weekly Surveillance Line Listing Report to monitor trends. The "Outbreak Plan" policy required an outbreak investigation when there was evidence of a possible outbreak of an emerging infectious disease. Facility records showed that one resident had more than one loose bowel movement (LBM) in 24 hours on January 30, 2026, and seven additional residents on the Transitional Care Unit (TCU) had more than one LBM in 24 hours between February 1 and February 2, 2026, and these residents were listed on the Outbreak Case-Patient Line List. However, nursing progress notes documented that another resident had two episodes of loose stools on two separate dates in early February 2026, and a different resident had multiple episodes of vomiting and multiple episodes of loose bowel movements, but these two residents were not included on the facility’s Outbreak Case-Patient Line List. During an interview, the IC nurse reported that residents with potential infectious symptoms were communicated to the DON during daily morning meetings or by verbal reporting and stated they only worked three days per week. The IC nurse explained that the previous DON initiated the GI symptom line list and then handed it off on February 2, 2026, but could not explain why the two additional symptomatic residents were not captured on the surveillance report and confirmed that no investigation was conducted to determine the source of the residents’ GI symptoms. The surveyors concluded that the facility failed to ensure appropriate surveillance, monitoring, and tracking for residents showing GI symptoms, citing 28 Pa. Code 201.18(b)(1), 211.5(f), and 211.12(d)(1)(3)(5).
Failure to Update Assignment Sheet Leads to Resident Injury During Transfer
Penalty
Summary
The facility failed to prevent accidents by not ensuring that the assignment sheet accurately reflected the care needs of a resident with Alzheimer's disease, osteoarthritis, and a history of repeated falls. The resident was involved in an incident where, while being transferred using a stand-up lift, she moved her left arm and did not hold onto the bar, resulting in a skin tear to her left forearm. Occupational therapy notes indicated that the resident had limited standing tolerance and required significant assistance and constant cues to keep her feet on the lift platform. It was also documented that transfers using the sit-to-stand lift should only be performed by CNAs familiar with her behavior and who had been educated on her specific needs. Despite these documented requirements, staff involved in the transfer were not fully aware of the resident's current transfer status, with one employee stating they believed the resident was cleared for the sit-to-stand lift based on previous information. The assignment sheet, which is used by CNAs to determine transfer statuses, was not updated to reflect the resident's need for a two-person transfer and the specific precautions required. Although competency evaluations and orientation for mechanical lift use were in place, the lack of accurate and updated information on the assignment sheet contributed to the incident.
Failure to Maintain Smoke Barrier Wall Integrity
Penalty
Summary
The facility failed to maintain the smoke resistance of smoke barrier walls, which is a requirement for ensuring fire safety within the building. During an observation, it was noted that there were two unprotected penetrations in the basement Linen Storage Room wall, where two pipes had been removed. This deficiency was confirmed through an interview with the Maintenance Manager, who acknowledged the unprotected penetrations of the smoke barrier wall. This issue affected two out of the 14 smoke compartments within the component, compromising the smoke resistance of the barrier walls.
Plan Of Correction
The two penetrations of the basement Linen Storage Room will be corrected by the Maintenance Manager using an approved through penetration fire stop system. The Maintenance Manager or designee will conduct an audit of corridor walls weekly for one month, then bi-weekly for one month. Monthly fire walls inspections will be added to PM schedule to check for penetrations and caulking in place and ensure that the facility is maintaining the rating of the smoke barrier wall. Deficient findings will be reported to DES and QAPI meeting.
Failure to Maintain Fire Resistance of Common Walls
Penalty
Summary
The facility failed to maintain the fire resistance of building separating common walls, which affected one of the 14 smoke compartments within the component. During an observation, it was noted that there were four unprotected penetrations in the common wall separating the 01 and 02 Components. These penetrations were located above the suspended ceiling, above the double doors, on the 01 Component side. Specifically, three penetrations were found around groups of wires, and one penetration was empty. This deficiency was confirmed through an interview with the Maintenance Manager, who acknowledged the unprotected penetrations of the fire wall.
Plan Of Correction
The four penetrations of the common wall, separating the 01 and 02 components above the suspended ceiling above the double doors will be corrected by the Maintenance Manager using an approved through penetration fire stop system. The Maintenance Manager or designee will conduct an audit of corridor walls weekly for one month. Monthly fire walls inspections will be added to PM schedule to check for penetrations and caulking in place to ensure the facility maintains the rating of the common wall. Deficient findings will be reported to DES and QAPI meeting.
Fire Resistance Deficiency in Stairwell Enclosure
Penalty
Summary
The facility failed to maintain the fire resistance of exit stairtower enclosures, specifically affecting one of the 14 smoke compartments. During an observation, it was noted that the fire exit hardware on the 1st floor Rosewood East Stairwell door was missing an end cap. This deficiency was confirmed through an interview with the Maintenance Manager, who acknowledged the compromised fire resistance of the fire exit hardware.
Plan Of Correction
1. The end cap on the fire exit hardware for Rosewood east stairwell door will be replaced. 2. The Maintenance Manager or designee will conduct an audit of the fire exit hardware weekly for one month. 3. Fire door hardware inspection will be added to the PM checklist to ensure all parts are on the fire doors. 4. Deficient findings will be reported to DES and QAPI meeting.
Deficiency in Smoke Resistance of Hazardous Area Enclosure
Penalty
Summary
The facility failed to maintain the smoke resistance of hazardous area enclosures, specifically affecting one of the 14 smoke compartments within the component. During an observation on January 28, 2025, at 12:30 PM, it was noted that the basement door to the Maintenance Storage Room, which is over 100 square feet, lacked an automatic closure. This deficiency was confirmed through an interview with the Maintenance Manager at the same time, who acknowledged that the door did not automatically close.
Plan Of Correction
A door closure will be installed on the basement maintenance storage. The Maintenance Manager or designee will conduct a facility wide audit on hazardous doors, and then random doors on a quarterly basis. Education will be provided to all staff on when to report doors missing hardware. Deficient findings will be reported to DES and QAPI meeting.
Unsecured Portable Fire Extinguisher in Facility
Penalty
Summary
The facility failed to secure a portable fire extinguisher, which was observed during a survey. The deficiency was identified in one of the 14 smoke compartments within the facility. Specifically, on January 28, 2025, at 12:20 PM, a portable fire extinguisher located in the basement Elevator Machine Room, near the vending machines, was found removed from its wall bracket and placed unsecured on the floor. This observation was confirmed through an interview with the Maintenance Manager at the same time.
Plan Of Correction
Fire extinguisher located within the elevator Machine Room was reinstalled onto the wall bracket. The Maintenance Manager, or designee will audit fire extinguisher placement for one month. Add to our monthly Fire Extinguishers checklist to ensure extinguisher is in mounting bracket. Education will be provided to all staff on the proper mounting of fire extinguishers, and the reporting when a bracket or cabinet is damaged. Deficient findings will be reported to DES and QAPI meeting.
Improper Use of Surge Suppressors and Extension Cords
Penalty
Summary
The facility failed to properly monitor the use of surge suppressors and extension cords, which led to a deficiency in one of the 14 smoke compartments. During an observation on January 28, 2025, at 12:45 PM, it was found that a surge suppressor was supplying electrical power to an extension cord, which then powered communications equipment in the basement Communications Room. This setup was confirmed by the Maintenance Manager during an interview at the same time. Additionally, another observation on the same day at 1:09 PM revealed a receptacle multiplying power tap supplying electrical power to a surge suppressor within the Chapelwood Communications Closet. This was also confirmed by the Maintenance Manager during an interview. These findings indicate a failure to adhere to the proper use of electrical equipment as per the NFPA standards, contributing to the deficiency noted in the report.
Plan Of Correction
An additional electrical outlet will be installed to supply electricity to the communication equipment. The multiplying power tap in the Chaplewood Communication closet has been removed. The Maintenance Manager or designee will conduct an audit for unauthorized electrical equipment not less than quarterly, and more frequently during high decoration holidays such as Christmas and Easter. Deficient findings will be reported to DES and QAPI meeting.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments, as evidenced by discrepancies in the Minimum Data Set (MDS) for three residents. For Resident 18, the quarterly MDS inaccurately indicated that the resident was receiving insulin, despite the absence of physician orders or documentation in the Medication Administration Record (MAR) confirming insulin administration. Similarly, Resident 31's MDS incorrectly noted insulin administration, which was not supported by physician orders or the MAR. These inaccuracies were confirmed through staff interviews. Additionally, Resident 52's MDS failed to reflect the presence of an unstageable pressure ulcer on the right heel, as documented in the resident's wound and skin records. The MDS inaccurately reported no unhealed pressure ulcers, contradicting the clinical documentation. These errors in the MDS assessments were confirmed by staff interviews, indicating a failure to accurately document and assess the residents' medical conditions.
Plan Of Correction
The following Resident Assessments were resubmitted for accuracy: Resident 18 Quarterly MDS 12/17/2024 was modified and resubmitted on 1/21/2025. Resident 31 Quarterly MDS 12/6/2024 was modified and resubmitted on 1/21/2025. Resident 52 Quarterly MDS 10/11/2024 was modified and resubmitted on 1/21/2025. An MDS audit for current residents' last assessment will be completed for resident assessments coded as receiving insulin and resident assessments coded as having wounds to ensure accuracy. Any identified modifications resulting in resubmission will occur. MDS staff received re-education on MDS completion by Nursing Home Administrator on 1/21/2025, accuracy and RAI guidelines. A weekly audit of 3 quarterly resident assessments for MDS accuracy will be completed by the NHA or designee x one-month. Random audits of 3 quarterly resident assessments for MDS accuracy x 2 months will be completed by NHA or designee. Findings will be reported to Quality Assurance for review and recommendations as appropriate.
Delayed Call Bell Response Times
Penalty
Summary
The facility failed to ensure that call bells were answered in a timely manner on both the first and second floors, as evidenced by a review of facility records and interviews with staff and residents. The facility's 'Call Bell Response' policy, which was undated, stated that call lights should be responded to promptly to promote a secure atmosphere for residents. However, a call bell response time report from November 1 to November 30, 2024, revealed an average response time of 28.07 minutes for 283 call alarms, with some response times extending up to 111.05 minutes. Interviews with several residents and a visiting family member confirmed concerns about prolonged call bell response times. One resident reported experiencing response times of more than 10 minutes but less than 60 minutes, while another reported waiting 20 minutes or more. Another resident experienced response times ranging from 45 minutes to over 60 minutes, corroborated by a family member who noted a 45-minute wait the previous night. The Nursing Home Administrator confirmed the lengthy response times and stated that response times over 40 minutes are investigated, often finding that staff were assisting other residents at the time.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. 1. Based upon the 2567, the facility is unable to determine which residents provided statements to the surveyor. An audit was conducted of the call bell response report for the entire month of November 2024. There was a total of 6,112 events with an average response time of 6.58 mins for all of them. An audit of Incident reports and the Grievance log for November 2024 did not indicate any incidents or complaints about prolonged wait for call bell response and no harm or injury was identified. 2. To prevent this from reoccurring, re-education for Nursing staff on the call bell policy and the importance of properly clearing call bell devices. 3. Ongoing monitoring for compliance, DON/designee will review call bell response time reports daily x 2 weeks than weekly x 2 months and investigate any prolonged wait times to ensure proper staff response to call bells. 4. Results will be presented at QAPI for review and revision.
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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) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Calvert Manor | 5.6 mi | ★★★★★ | 4 | 0 |
| Preston Residence | 6.1 mi | ★★★★★ | 0 | 0 |
| Twin Pines Health Care Center | 10.4 mi | ★★★★★ | 8 | 0 |
| Quarryville Presbyterian Retirement Community | 11.9 mi | ★★★★★ | 16 | 0 |
| Newport Meadows Health And Rehabilitation Center | 12.1 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.