Health inspection·January 16, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to ensure that resident assessments accurately reflect the residents' status for three of 24 residents reviewed. (Resident 18, Resident 31, and Resident 52). Residents Affected - Few Findings include: Review of Resident 18's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated December 17, 2024, revealed under section N0350 - Insulin, that the resident was marked as receiving insulin medication. Review of Resident 18 physician's orders revealed that the resident was not ordered insulin. Review of the Medication Administration Record (MAR) revealed that the resident did not receive insulin. Interview with the licensed staff, Employee E3, on January 15, 2025, at 1:08 p.m. confirmed that the resident's MDS assessment was marked incorrectly. Review of Resident 31's quarterly MDS of December 6, 2024, section N0350-Insulin, indicated that the resident received an injection of insulin once in the last seven days. Review of physician's orders and MAR revealed no evidence that the resident received insulin. Interview with licensed staff, Employee E3, on January 15, 2025, at 1:08 p.m. confirmed that the MDS was marked incorrectly. Review of Resident 52's wound and skin documentation dated October 10, 2024, revealed resident had an unstageable pressure ulcer (full thickness tissue loss where the depth cannot be assessed due to the presence of necrotic tissue [dead or dying cells] to the right heel. Review of quarterly MDS of October 11, 2024, section M0210-Unhealed Pressure Ulcers indicated Resident 52 did not have any unhealed pressure ulcers. Interview with licensed staff, Employee E3, on January 16, 2025, at 11:14 a.m. confirmed that the MDS was marked incorrectly. 483.20 Resident Assessments Previously cited 2/15/24 Page 1 of 2 395367 395367 01/16/2025 Oxford Health Center 7 East Locust Street Oxford, PA 19363

F 0641 28 Pa. Code 211.5(f) Clinical records Level of Harm - Minimal harm or potential for actual harm Previously cited 2/15/24 28 Pa. Code 211.12(c) Nursing services Residents Affected - Few Previously cited 2/15/24 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 2/15/24 395367 Page 2 of 2