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Inspection visit

Health inspection

OXFORD HEALTH CENTERCMS #3953671 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

395367 12/09/2024 Oxford Health Center 7 East Locust Street Oxford, PA 19363
F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on facility record reviews, and staff and resident interviews it was determined that the facility failed to ensure call bells were answered in a timely manner on two of two floors. (First & Second Floor) Residents Affected - Few Findings include: Review of facility records revealed a Call Bell Response policy, undated, that documents call lights/alerts will be responded to in a timely fashion. The purpose being to respond promptly to resident calls for assistance and promote a secure atmosphere for residents. All nursing personnel must be aware of call lights/alerts at all times. Staff should answer bells/alerts promptly whether or not they are assigned to the resident Review of facility records revealed a call bell response time report dated December 9, 2024, documenting call bell response times, over 15 minutes, from November 1, 2024, thru November 30, 2024. Review of the report revealed a total of 283 call alarms with an average response time of 28.07 minutes. Further review of the report revealed response times as long as 111.05 minutes. Interviews with Residents R1, R3, R4, and R6, on December 9, 2024 revealed the residents had concerns with call bell response times. Interview with Resident R1 on December 9, 2024 at 9:45 a.m. revealed he/she experienced long call bell response times but R1 was unable to provide specific timeframes. Interview with Resident R3 on December 9, 2024 at 9:52 a.m. revealed he/she experienced call bell response times of more than 10 minutes or more but less than 60 minutes. Interview with Resident R4 on December 9, 2024 at 10:00 a.m. revealed he/she experienced call bell response times of 20 minutes or more. Interview with Resident R6 on December 9, 2024 at 10:06 a.m. revealed he/she experienced call bell response times of 45 minutes to over 60 minutes. Interview with visiting family member on December 9, 02204 at 10:20 a.m. revealed R6 called the previous night complaining that he/she had been waiting 45 minutes for staff to answer his/her call bell. Page 1 of 2 395367 395367 12/09/2024 Oxford Health Center 7 East Locust Street Oxford, PA 19363
F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON) on December 9, 2024, at 3:15 p.m. when the above information was presented, the NHA confirmed call bell response times up to 111.05 minutes. The NHA stated call bell response times are an ongoing objective of their Quality Assurance Performance Improvement (QAPI) strategy planning. The NHA stated all response times over 40 minutes are investigated. Per the NHA the findings of the investigations usually result in staff assisting other residents at the time call bells are rung. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing Services 395367 Page 2 of 2

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0558GeneralS&S Dpotential for harm

    F558 - The right to reside and receive services in the facility with reasonable

    Reasonably accommodate the needs and preferences of each resident.

FAQ · About this visit

Common questions about this visit

What happened during the December 9, 2024 survey of OXFORD HEALTH CENTER?

This was a inspection survey of OXFORD HEALTH CENTER on December 9, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at OXFORD HEALTH CENTER on December 9, 2024?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.