Health inspection·February 15, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews it was determined that the facility failed to ensure the dignity of residents in one of the four units observed (Dementia Unit). Findings include: Observation conducted during the environmental tour of the rooms in the Dementia Unit on February 11, 2024, at 10:22 a.m. The observation revealed room [room number] was occupied by two residents. A white paper with a typewritten note indicating Please use XL (extra-large) pull up with underwear over top and remind resident it's ok to urinate in underwear if can't make it to the bathroom was posted above Resident 43's bed (A) which was visible to the people walking in the hallway. Observation conducted on February 15, 2024, at 10:00 a.m., revealed the same message noted above continued to be posted on Resident 43's wall above the bed. Interview conducted with unlicensed staff, Employee E5, on February 15, 2024, at 10:15 a.m., revealed that the note had been posted on the resident's wall for a couple of weeks now but was not sure who did it. Interview conducted with the Nursing Home Administrator (NHA) on February 15, 2024, at 1:00 p.m., The NHA confirmed that the note was not posted by the resident's family. The NHA was unable to determine who posted the note mentioned above. The NHA confirmed that resident personal information should have not been posted visible to the public. The facility failed to ensure the dignity of Resident 43 was maintained by posting private information visible to the public. 28 Pa. Code 201.29(j) Resident Rights 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services Page 1 of 5 395367 395367 02/15/2024 Oxford Health Center 7 East Locust Street Oxford, PA 19363

F 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based upon review of facility policy and procedure and clinical record review, it was determined the facility failed to report to the State agency an allegation of abuse for one of 24 residents reviewed (Resident 28). Residents Affected - Few Findings include: Review of facility policy and procedure titled Abuse, Neglect or Exploitation, revised 10/24/2022, revealed For Skilled Facilities covered under the Elder Justice Act an individual must report any alleged violations of abuse OR if there was serious bodily injury the facility MUST report the allegation to the DOH IMMEDIATELY BUT NO LATER THAN 2 HOURS AFTER THE ALLEGATION IS MADE. For those allegations that are neglect, exploitation, misappropriation of resident property, or mistreatment that do NOT result in serious bodily injury, the facility must report the allegation no later than 24 hours. Review of Resident 28's clinical progress notes dated December 2, 2023, revealed CNA's following care plan and two assist with all care. After resident received a bed bath turned to female CNA and stated he is being rough with me. Female CNA reported that she had been present and assisting throughout care. Observed no such behavior. Nurse provided privacy and asked resident the following questions: How was your bed bath? replied ok. Do you feel clean? Replied yes. Are you having any pain or discomfort? replied no. Do you feel safe? replied yes. Made supervisor aware. Revisited resident. Asked the following: Are you ok? replied yes and smiled. Are you happy with the care and bed bath you received? Replied yes Are you having any pain or discomfort? Replied no and smiled. Asked if resident need to talk about anything? replied no, I'm okay. Are you ok with the people that gave you a bed bath? Yes. Do you feel safe? Replied yes. Supervisor updated. Review of facility documentation and clinical record failed to reveal evidence the above allegation of abuse was reported to the State agency. Interview with the Nursing Home Administrator and Director of Nursing on February 15, 2024, at 11:00 a.m. confirmed the above allegation was not reported to the State Agency. 28 Pa. Code 201.18(a)(b)(1)(2)(g)(1) Management 395367 Page 2 of 5 395367 02/15/2024 Oxford Health Center 7 East Locust Street Oxford, PA 19363

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based upon review of facility policy and procedure and clinical record review, it was determined the facility failed to thoroughly investigate an allegation of abuse for one of 24 residents reviewed (Resident 28). Residents Affected - Few Findings include: Review of facility policy and procedure titled Abuse, Neglect or Exploitation, revised 10/24/2022, revealed Events involving evidence or reports of physical, sexual, mental or verbal abuse, involuntary seclusion, neglect and misappropriation of resident's property shall be thoroughly investigated including obtaining statements from all potential persons who might have had contact with the resident in the previous 24 ours or within the timeframe that has been identified. Review of Resident 28's clinical progress notes dated December 2, 2023, revealed CNA's following care plan and two assist with all care. After resident received a bed bath turned to female CNA and stated he is being rough with me. Female CNA reported that she had been present and assisting throughout care. Observed no such behavior. Nurse provided privacy and asked resident the following questions: How was your bed bath? replied ok. Do you feel clean? Replied yes. Are you having any pain or discomfort? replied no. Do you feel safe? replied yes. Made supervisor aware. Revisited resident. Asked the following: Are you ok? replied yes and smiled. Are you happy with the care and bed bath you received? Replied yes Are you having any pain or discomfort? Replied no and smiled. Asked if resident need to talk about anything? replied no, I'm okay. Are you ok with the people that gave you a bed bath? Yes. Do you feel safe? Replied yes. Supervisor updated. Review of facility documentation and clinical record failed to reveal evidence the above allegation of abuse was thoroughly investigated by the facility. Interview with the Nursing Home Administrator and Director of Nursing on February 15, 2024, at 11:00 a.m. confirmed the above allegation was not thoroughly investigated by the facility. 28 Pa. Code 201.18(a)(b)(1)(2)(g)(1) Management 395367 Page 3 of 5 395367 02/15/2024 Oxford Health Center 7 East Locust Street Oxford, PA 19363

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interview, it was determined that the facility failed to ensure that assessments accurately reflected the resident's status for two of 24 residents reviewed (Residents 82 and 84). Residents Affected - Few Findings include: Review of Resident 82's MDS Assessment (periodic assessment of resident needs) dated January 2, 2024, revealed a discharge status of home/community. Review of Resident 82's nursing progress notes dated January 2, 2024, at 12:55 p.m., revealed Nurse Practitioner ordered to transfer the resident to the ER (Emergency Room) due to acute left-sided abdominal pain. Review of the nursing progress notes dated January 2, 2024, at 6:48 p.m., revealed that after the evaluation from [name of hospital] ER, Resident 82 was transferred to another hospital where she/he had previous surgery. The family will be coming to gather personal items. Interview conducted with the RNAC (Registered Nurse Assessment Coordinator) Employee E3, on February 15, 2024, at 11:00 a.m., confirmed that the Resident was sent to the hospital and was not discharged to home/community on January 2, 2024. Review of Resident 84's discharge MDS assessment dated [DATE], Section A2105 Discharge Status, indicated that the resident was discharged to an acute hospital. Review of Resident 84's clinical record including nursing progress note dated November 15, 2023, revealed that the resident was discharged home on November 14, 2023. During an interview with the RNAC , Employee E3, on February 15, 2024, at 10:08 a.m. confirmed that the resident was discharged home and that the MDS assessment was marked incorrectly. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 4/20/23 395367 Page 4 of 5 395367 02/15/2024 Oxford Health Center 7 East Locust Street Oxford, PA 19363

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on review of clinical records and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 18 residents reviewed (Resident 141). Residents Affected - Few Findings include: Review of Resident 141's admission MDS (Minimum Data Set - periodic assessment of resident needs) of February 5, 2024, revealed that the resident had an indwelling catheter (flexible tube placed in the bladder to drain urine). Review of the current physician's orders also indicated that the resident had a catheter. Further review of the clinical record failed to reveal a care plan related to the indwelling catheter. Interview with Employee E4, corporate representative, on February 15, 2024, at 9:13 a.m. confirmed that a care plan for the catheter was not developed until February 14, 2024. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 4/20/23 395367 Page 5 of 5