Oxford Rehabilitation & Health Care Center, The

F-F609

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm 48671

Residents Affected - Few Based on interviews and records reviewed, the facility failed to report an allegation of abuse to the State Agency for one Resident (#55) out of a total sample of 25 residents.

Findings include:

Review of the facility policy titled Abuse, Neglect and Exploitation dated 2/2023, indicated but was not limited to the following:

-It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.

-Abuse means the willful infliction of injury unreasonable confinement intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercation's Abuse also includes the deprivation of any individual, including a caretaker, of goods or services that are necessary to attain or maintain physical mental and psychosocial well-being instances of abuse of all residents irrespective of any mental or physical condition, can cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.

A. The facility will have written procedures that include:

1. Reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable within specified timeframes:

a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious body injury, or

b. No later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Resident #55 was admitted to the facility in October 2022 with diagnoses including major depressive disorder, anxiety, repeated falls and muscle weakness.

Review of the most recent Minimum Data Set (MDS) assessment, dated 2/14/25, indicated that Resident #55 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. This MDS indicated Resident #55 required supervision or touching assistance with walking.

On 2/25/25 at 8:32 A.M., the surveyor reviewed the two grievance forms dated 2/24/25. The grievance forms indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Grievance #1 indicated: On 2/22/25 (Resident in wheelchair) and Resident #55 and (third Resident) were in

the elevator when it went to 2nd (floor). I was by the buttons when (Resident in wheelchair) told me to get out Level of Harm - Minimal harm or so he/she could get out. I was not in his/her way and I said you have plenty of room, then he/she told me I potential for actual harm would be sorry when he/she rolled over my feet. I told him/her go ahead. It escalated by him/her calling me a bitch and other words. I responded by saying them back. That's when (third Resident) started laughing. Residents Affected - Few (Resident in wheelchair) said he/she never liked me and I told him/her the same was mutual. (Third Resident) was blocking the elevator so I couldn't leave and go to my floor. I finally told him/her to please move and then he/she did.

Grievance #2 indicated: On 2/23/25 the security guard started accusing me of staring with (Resident in wheelchair from Grievance form one) and wouldn't listen to me. He did it so unprofessional cause other residents heard him. He told me he was going to the Substance Abuse Counselor, Administrator In Training (AIT), and Social Worker to have me thrown out cause he believes (Resident in wheelchair).

Grievance #1 and Grievance #2 was signed as received on 2/24/25 by Social Worker.

The grievance form was signed and dated 2/25/25, by the AIT, Social Worker and Unit Manager #1 as reviewed and resolved.

During an interview on 2/24/25 at 8:40 A.M., Resident #55 said he/she submitted two grievance forms to the social worker regarding an altercation with another resident in the elevator on 2/22/25. Resident #55 said the other resident threatened and rolled over his/her feet in the elevator. Resident #55 said he/she had a verbal altercation with the security guard on 2/23/25. Resident #55 said the security guard threatened to have him/her thrown out of the facility because he did not like the way Resident #55 was speaking to the resident

in the elevator the day prior. Resident #55 said the security guard embarrassed and threatened him/her in front of other residents and said he doesn't like me and threatened to have Resident #55 thrown out of the facility. Resident #55 said he/she was upset and embarrassed by both situations and said he/she submitted

a grievance form and told the Social Worker, but they won't do anything about it.

During an interview on 2/25/25 at 11:02 A.M., the Social Worker said she received two grievance from Resident #55 and said she did not feel they warranted to be reported because it was a verbal altercation with another resident and she gave the forms to the Administrator and with the expectation for customer service education to be done with the security guard. The surveyor then reviewed both grievance forms with the Social Worker. The Social Worker said she should have read the forms entirely and said threatening to roll over the resident's foot and threatening to have the Resident thrown out of the facility is concerning for verbal abuse.

During an interview on 2/25/25 at 12:48 P.M., with the Administrator, AIT, and the Director of Nurses (DON),

the Administrator said he would expect the incidents to have been reported. The AIT said allegations of suspected abuse must be reported. The DON said they do not have any further details or reporting information at this time and said they are starting the process now.

During an interview on 2/27/25 at 10:29 A.M., Director of Nurses (DON) said an investigation into the allegations should have been started on 2/24/25 and should have been reported per policy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Review of the Health Care Facility Reporting System (HCFRS) indicated the abuse allegation was submitted

on 2/25/25; 24 hours after the allegation was made to the Social Worker. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm 41105

Residents Affected - Few Based on observation and interview, the facility failed to implement the care plan for one Resident (#6) out of

a total sample of 20 residents. Specifically, the facility failed to ensure that the call light was within reach of Resident #6 while he/she was in bed.

Findings include:

The facility policy titled Call Light, Use of, dated April 2015, indicated the following:

-All residents/patients will have a call light or alternative communication device within his/her reach when unattended.

Resident #6 was admitted to the facility in January 2011 and has diagnoses that include dysphagia (difficulty chewing and swallowing) and hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side (stroke).

Review of the most recent Minimum Data Set (MDS) assessment, dated 2/20/25, indicated that on the Brief

Interview for Mental Status exam Resident #6 scored a 15 out of a possible 15, indicating intact cognition.

The MDS further indicated Resident #6 requires substantial to maximal assistance with bed mobility.

Review of the current Functional mobility care plan for Resident #6 indicated the following intervention:

-Total dependent on 2 staff.

Review of the current at risk for falls care plan for Resident #6 indicated the following intervention:

-Call light within reach.

During an observation and interview on 3/19/25 at 8:02 A.M., Resident #6 was observed in bed and his/her call bell was dangling behind the right side of the bed out of reach. Resident #6 said that he/she needed straws but could not call staff for help getting them because he/she could not reach the call bell. Resident #6 said, the next time I see them will be when they come to pick up my tray.

During an interview on 3/19/25 at 10:33 A.M., Certified Nurse Assistant (CNA) #2 said that Resident #6 requires total assistance and should have a call bell within reach when he/she is in bed.

During an interview on 3/19/25 at 10:58 A.M., with the Occupational Therapist she that she noticed when she was in Resident #6's room after breakfast that his/her call bell was out of reach behind the bed. The Occupational Therapist said you shouldn't have to write these basic thing on a sign but I will put a new one up today and add a reminder to staff to have Resident #6's call bell within reach

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During an interview on 3/19/25 at 11:24 A.M., the Director of Nursing said that call bells should be within reach when residents are in bed. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44095 potential for actual harm Based on observations, and interviews, the facility failed to ensure residents on the first-floor unit were Residents Affected - Few provided with care in accordance with professional standards of practice. Specifically, two different surveyors at two different times observed Nurse #1 prepare and administer medications without referencing the medication administration record in the electronic health record.

Findings include:

Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019 indicated the following:

-The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice.

Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following:

-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.

Review of the facility policy titled, Medications Administration - Oral, dated as revised June 2015, indicated:

1. Verify medication order of the Medication Administration Record (MAR).

5. Only prepare one resident medication at a time.

6. Compare the medication label to the resident's MAR.

9. Verify the medication is being administered at the proper time, in the prescribed dose, and by the correct route.

14. Do not touch the medication when opening the bottle or unit dose packaging.

1. On 3/19/25 between 7:16 A.M., through 7:24 A.M., the surveyor made a continuous observation of Nurse #1 going between two medication carts on the first-floor unit, neither of the medication cart's computer screens were open to the medication administration record in the electronic health record. The surveyor observed Nurse #1 preparing medications from several different prescription medication cards, over the counter bottles, and the surveyor observed Nurse #1 removing narcotics from the narcotic drawer without referencing the narcotic book. Nurse #1 placed the prepared medication cups in the top drawer of the medication cart. During this observation two different Residents came to the medication cart and Nurse #1 handed each resident a cup of medications from the top drawer of the medication cart without referencing

the electronic health record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 During an interview on 3/19/25, at 7:42 A.M., Nurse #1 said that she should not be preparing medications without reviewing the physician's orders. Level of Harm - Minimal harm or potential for actual harm 2. On 3/19/25 at 7:40 A.M., the surveyor observed Nurse #1 preparing medications from several different medication cards and place them in a medication cup without reviewing the electronic health record. The Residents Affected - Few surveyor observed the computer on top of the medication cart to be a blank blue screen while Nurse #1 was preparing the medications.

During an interview on 3/19/25 at 7:49 A.M., Nurse #1 said that she was not following the medication administration policy, and she was preparing and administering medications from her memory. Nurse #1 said sometimes bad habits are hard to break.

During an interview on 3/19/25 at 11:00 A.M., the Director of Nursing said that Nurse #1 should have reviewed the electronic health record during the medication pass.

36797

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or 41105 potential for actual harm Based on observation and interview, the facility failed to provide assistance with Activities of Daily Living Residents Affected - Few (ADL) for one Resident, (#52), out of a total sample of 25 residents. Specifically, for Resident #52 the facility failed to provide assistance with feeding.

Findings include:

Review of the facility policy titled Activities of Daily Living, dated as April 2015, indicated:

-A program of assistance and instruction in ADL skills is developed and implemented based on the individual evaluation to encourage the highest level of functioning.

Resident #52 was admitted to the facility in July 2022 and has diagnoses that include vascular dementia and dysphagia (difficulty chewing and swallowing).

Review of the most recent Minimum Data Set (MDS) assessment, dated 12/6/24, indicated that on the Brief

Interview for Mental Status exam Resident #52 scored a 4 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #52 required supervision or touching assistance for eating.

Review of Resident #52's care card, dated as revised on 12/2024, indicated for eating: Substantial/ maximum assistance.

Review of the current Activities of Daily Living (ADL) care plan for Resident #52 indicated the following intervention: Eating: max assist, dated as revised on 2/24/25.

Review of the POC (point of care) responses to the task of eating indicated that in the past 14 days Resident #52 required variable assistance with meals. Staff documented Resident #52 required the following level of assistance with feeding:

-Setup: 4 times

-Supervision or touching assistance: 11 times

-Partial/moderate assistance: 7 times

-Substantial/maximal assistance: 7 times

On 2/24/25 at 8:25 A.M., Resident #52 was observed in the unit dining room trying to feed self eggs. As Resident #52 attempted to feed him/herself the eggs repeatedly fell off the fork into Resident #52's lap. Resident #52 resorted to eating the eggs with his/her hands. Throughout the observation a nurse stood within 5-6 feet of the Resident facing him/her and did not intervene or offer assistance to Resident #52.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 On 2/26/25 between 8:09 and 8:14 A.M., Resident was seated in a chair in the unit dining room. Resident #52's bodies was leaning so far to the left that his/her left hand was an inch from the floor. As Resident #52 Level of Harm - Minimal harm or attempted to feed himself/herself eggs with a plastic food fork the eggs repeatedly fell to the floor. At 8:12 A. potential for actual harm M., Resident #52 began eating the scrambled eggs with his/her hands. Throughout the observation the Director of Social Work stood within 5-6 feet of the Resident facing him/her and did not intervene, offer Residents Affected - Few assistance or find staff to assist the Resident.

On 2/26/25 at 12:03 P.M., Resident #52 was observed seated in a chair in the unit dining room. A staff person served the lunch, partially set up the meal and then left the table to continue passing meals to other residents. The surveyor continued to make the following observations:

-At 2:07 P.M., a staff person walked over to Resident #52, opened the milk container and poured it into Resident #52's cup, placed a chair beside him/her and walked away.

-At 12:08 P.M., Resident #52 dropped food off the plastic fork he/she was using into his/her lap.

-At 12:10 P.M., Resident #52 reached for cup of milk, and as he/she struggled to carry it to his/her mouth, Resident #52 rested his/her hand in meat and gravy.

-At 12:11 P.M., Resident #52 used his/her hand to eat green beans.

-At 12:11 P.M., Resident #52 used the meal ticket to his/her wipe mouth.

-By 12:12 P.M., no staff had offered or assisted Resident #52 with the meal.

During an interview on 2/27/25 at 8:36 A.M., Certified Nurse Assistant (CNA) #1 said that Resident #52 requires feeding assistance with meals. CNA #1 said that she knows the care Resident #52 needs based on his/her care card. CNA #1 showed the surveyor Resident #52's care which indicated he/she required substantial/maximal assistance with eating.

During an interview on 2/27/25 at 8:42 A.M., Unit Manager #2 said CNAs should provide the assistance based on the care card, Unit Manager #2 said that Resident #52 has been declining over the past few days, and he/she needs more assistance. Unit Manager #2 said that if the CNAs are not available the Nurse or anyone who is available, can assist during meals. The surveyor reviewed the surveyor's observations from 2/24/25 and 2/26/25 and Unit Manager #2 said that staff should intervene when the Resident is struggling.

During an interview on 2/27/25 at 12:08 P.M., the Director of Nursing said that nursing should provide assistance with meals in accordance with the plan of care.

44095

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36876 potential for actual harm Based on observation, record review and interview, the facility failed to ensure interventions related to Residents Affected - Few pressure injury healing were implemented for two Residents, (#5 and #39), out of a total of 25 sampled Residents. Specifically, the facility failed to ensure Resident #5 and Resident #39's air mattresses was on

the correct setting.

Findings include:

Review of the facility policy titled Support Surface' undated, indicated the following but not limited to:

-A physician's order is required for the use of a specialty support surface. The order shall include the type of mattress, the mode (alternating or static), and setting.

-Specialty support surfaces will be checked each shift for proper functioning and or inflation.

1. Resident #5 was admitted to the facility in July 2023 with diagnoses including traumatic brain injury and hemiplegia and hemiparesis.

Review of the Minimum Data Set Assessment (MDS) dated [DATE REDACTED] indicated Resident #5 is moderately cognitively impaired evidenced by a score of 11 out of a possible 15. The MDS also indicated Resident #5 is dependent on staff for all activities of daily living and weighed 139 lbs (pounds).

On 2/24/25 at 9:14 A.M., the surveyor observed Resident #5 resting in bed. Resident #5 appeared thin and frail and said that he/she was not comfortable. The surveyor observed the air mattress was set at 325 lbs.

Review of Resident #5's clinical record indicated he/she had developed an unstageable pressure injury to his/her sacrum in January 2025.

Review of Resident #5's physicians order dated 2/6/25 indicated: Specialty air mattress. Set at 150. Check setting and function every shift.

On 2/25/25 at 12:14 P.M. and 2/26/25 at 8:09 A.M., the surveyor observed Resident #5 laying in bed with the air mattress set at 325 lbs.

During an interview on 2/26/25 at approximately 8:12 A.M., Nurse # 2 said that air mattress setting is based

on weights and orders. Nurse #2 said he thought Resident #5's air mattress should be set at 200 lbs and he/she would check.

During an interview on 2/2/25 at approximately 8:20 A.M., Unit Manager #1 said that Resident #5's air mattress should be set based on the physician's order.

46339

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 2. Resident #39 was admitted to the facility in November 2024 with diagnoses including chronic respiratory failure, interstitial pulmonary disease. Level of Harm - Minimal harm or potential for actual harm Review of Resident #39's Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated the Resident was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). Residents Affected - Few

On 2/24/25 at 8:54 A.M., the surveyor observed the Resident sitting on his/her bed the air mattress dial was set at 80 lbs. (pounds).

On 2/24/25 at 12:01 P.M., the surveyor observed the Resident sitting on his/her bed the air mattress dial was set at 80 lbs.

On 2/25/25 at 7:42 A.M., the surveyor observed the Resident sitting on his/her bed the air mattress dial was set at 80 lbs. The Resident said he/she does not change the settings.

Review of the Resident's current physician orders indicated the following:mSpecialty air mattress check setting and function every shift (set at 180) per patient request.

Review of the Resident's care plan for potential alteration in skin integrity: with intervention initiated 2/11/25 indicated the following: Air mattress per request set at 180.

During an observation and interview on 2/25/25 at 11:16 A.M., Nurse #4 said the air mattress should be set at the correct setting per the physician order. She further said the nurses are responsible for ensuring the air mattress is at the correct setting.

During an interview on 2/26/25 at 10:00 A.M., the Director of Nursing (DON) said physician orders are to be followed as ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46339 potential for actual harm Based on observation, interview and record review, the facility failed to provide respiratory care consistent Residents Affected - Few with professional standards of practice for one Resident, (#39), out of a total sample of 25 residents. Specifically, the facility failed to ensure oxygen was administered at the correct setting.

Findings include:

Review of facility policy titled Oxygen Administration Nasal Cannula dated November 2020, indicated the following but not limited to:

-To deliver low oxygen flow per physician's order (generally 1-6 LPM (liters per minute) and 24% -45% concentration) via nasal cannula.

-Set the oxygen liter flow to the prescribed liters flow per minute.

Resident #39 was admitted to the facility in November 2024 with diagnoses including chronic respiratory failure with hypercapnia, interstitial pulmonary disease.

Review of Resident #39's Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated the Resident was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). MDS further indicated the Resident was on oxygen.

On 2/24/25 at 8:54 A.M., the surveyor observed Resident #39 sitting on his/her bed wearing a nasal oxygen cannula. The oxygen concentrator was set at a flow rate of 2.5 liters per minute.

On 2/24/25 at 12:01 P.M., the surveyor observed Resident #39 sitting on his/her bed wearing a nasal oxygen cannula. The oxygen concentrator was set at a flow rate of 2.5 liters per minute.

On 2/25/25 at 7:42 A.M., the surveyor observed Resident #39 sitting on his/her bed wearing a nasal oxygen cannula. The oxygen concentrator was set at a flow rate of 2 liters per minute.

Review of the current physician's orders for Resident #39 indicated the following:

-Oxygen via nasal cannula at 4 liters per minute every shift for COPD (chronic obstructive pulmonary disease) check pulse oximeter and liters per minute.

Review of Resident #39 plan of care for COPD requiring supplemental oxygen continuously date revised 11/18/24 with the following intervention:

-Administer oxygen and monitor effectiveness by checking saturation as/if indicated.

-Oxygen via nasal cannula at 4 liters/minute check pulse oximeter every shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 During an observation and interview on 2/25/25 at 11:16 A.M., Nurse #4 said the oxygen should be set at the correct setting per the physician orders. She further said nurses should be checking every shift. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/26/25 at 10:00 A.M., the Director of Nursing (DON) said physician orders are to be followed as ordered. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 44095 potential for actual harm Based on observations, interviews, and record reviews for two Residents, (#50 and #16), out of three Residents Affected - Some residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. When one out of two nurses observed made three errors out of 28 opportunities resulting in a medication error rate of 10.71%. Specifically:

1.) For Resident #50, Nurse #1 administered Linzess (oral medication for constipation) after a meal when the medication was ordered to be administered 30 minutes before a meal.

2.) For Resident #16, Nurse #1 administered the incorrect dose (two sprays instead of one) of a nasal spray (Azelastine HCL, used for allergies) and Nurse #1 failed to administer the correct fiber medication (psyllium husk instead of calcium polycarbophil).

Findings include:

Review of the facility policy titled, Medications Administration - Oral, dated as revised June 2015, indicated:

1. Verify medication order of the Medication Administration Record (MAR).

6. Compare the medication label to the resident's MAR.

9. Verify the medication is being administered at the proper time, in the prescribed dose, and by the correct route.

1.) Resident #50 was admitted to the facility in January 2018 with diagnoses including anxiety, depression, and chronic idiopathic constipation.

Review of the most recent Minimum Data Set (MDS) assessment, dated 1/17/25, indicated that Resident #50 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15.

On 2/26/25 at 8:18 A.M., the surveyor observed Nurse #1 prepare and administer Resident #50's morning medications. Resident #50 said he/she had already eaten his/her breakfast and there was no longer a breakfast tray with the Resident. Nurse #1 prepared and administered the following:

- Linzess 145 micrograms (mcg), 1 capsule. Review of the medication bottle indicated the following take this medicine on an empty stomach, at least 30 minutes before the first meal of the day.

Review of Resident #50's physician's order, dated 1/29/24, indicated:

- Linzess Oral Capsule 145 mcg, give one capsule by mouth one time a day for constipation. Additional directions indicate to administer the medication 30 minutes prior to breakfast. Additional Administration notes indicate 7:00 A.M.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 During an interview on 2/26/25 at 1:54 P.M., Nurse #1 reviewed Resident #50's Linzess order and medication bottle and she said that the Linzess is ordered 30 minutes prior to breakfast, but she did not Level of Harm - Minimal harm or administer the medication prior to breakfast. potential for actual harm

During an interview on 2/26/25 at 1:58 P.M., Unit Manager #2 said Resident #50's Linzess should be Residents Affected - Some administered before breakfast.

During an interview on 2/26/25 at 2:55 P.M., the Director of Nursing said nursing should administer medications as ordered.

2.) Resident #16 was admitted to the facility May 2016 with diagnosis including chronic obstructive pulmonary disease, diabetes, and irritable bowel syndrome.

Review of the most recent Minimum Data Set (MDS) assessment, dated 12/6/24, indicated that Resident #16 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15.

On 2/26/25 at 8:32 A.M., the surveyor observed Nurse #1 prepare and administer Resident #16's morning medications. Nurse #1 prepared and administered the following:

- Azelastine HCL Solution 0.1%, 2 sprays in each nostril.

- Psyllium Husk, one capsule. Further review of the medication bottle indicated the serving size was 5 capsules.

Review of Resident #16's physician's order, dated 2/2/23, indicated:

- Azelastine HCL Solution 0.1%, give one spay in both nostrils two times a day related to chronic obstructive pulmonary disease.

- FiberCon Oral Tablet (Calcium Polycarbophil), give one tablet by mouth two times a day related to irritable bowel syndrome.

During an interview on 2/26/25 at 8:33 A.M., Resident #16 said he/she took 2 sprays into each of his/her nostrils and that is how he/she takes the medication every day.

During an interview on 2/26/25 at 1:56 P.M., Nurse #1 said Resident #16 should have only received one spray of the nasal spray in each nostril but did not. Nurse #1 said that she provided one capsule of the psyllium husk because that is what is provided by the facility.

During an interview on 2/26/25 at 1:59 P.M., Unit Manager #2 said Resident #16's medications should be administered as ordered by the physician. Unit Manager #2 and the surveyor reviewed literature which indicated that psyllium husk and calcium polycarbophil are not the same medication. Unit Manager #2 said

the facility should have the correct over the counter medications available for administration.

During an interview on 2/26/25 at 2:57 P.M., the Director of Nursing said nursing should administer medications as ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 45984 Residents Affected - Some Based on observations and interviews, the facility failed to ensure drugs and biologicals were stored in accordance with acceptable professional standards of practice. Specifically, the facility failed to 1. Ensure a treatment room containing resident-specific creams, lotions and other biologicals was locked while unattended on the first floor unit and 2. Ensure medication carts were locked while unattended by staff on the first and second floor units.

Findings include:

Review of the facility policy titled Medication Storage Room/Medication Cart Policy, dated and revised January 2025, indicated the following:

- Medications are stored primary in a locked mobile medication cart which is accessible only to licensed nursing personnel.

- Storage for other medications will be limited to a locked medication room.

- The medication cart is to be kept locked at all times when not in use by the nurse. The medication cart is to be locked when stored in the medication room or some other location.

1. The surveyor made the following observations on the first-floor medication treatment room next to the nursing station:

- On 2/24/25 from 8:28 A.M. through 8:42 A.M., the medication treatment room door was open, no staff were

in the room and residents were observed walking by it. Inside the treatment room was a shelf of treatment materials and an unlocked treatment cart containing resident-specific creams, lotions and other biologicals.

The surveyor was able to open and access the treatment cart inside the room.

- On 2/24/25 at 12:11 P.M., the medication treatment room door was open, no staff were in the room and a resident was observed walking into the treatment room. Inside the treatment room was a shelf of treatment materials and an unlocked treatment cart containing resident-specific creams, lotions and other biologicals.

The surveyor was able to open and access the treatment cart inside the room.

- On 2/25/25 at 6:49 A.M., the medication treatment room door was open, no staff were in the room and residents were observed walking by it. Inside the treatment room was a shelf of treatment materials and an unlocked treatment cart containing resident-specific creams, lotions and other biologicals.

- On 2/26/25 at 7:52 A.M., the medication treatment room door was open, no staff were in the room and residents were observed walking by it. Inside the treatment room was a shelf of treatment materials and an unlocked treatment cart containing resident-specific creams, lotions and other biologicals. The surveyor observed a latex gloved stuffed into the latch of the door which was preventing the door from latching properly and locking.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 During an interview on 2/26/25 at 8:37 A.M., Unit Manager #1 said the treatment room contains creams, ointment, biologicals and other treatment materials for residents and it should be locked at all times. Unit Level of Harm - Minimal harm or Manager #1 continued to say the treatment cart inside the room is open because the door to the room should potential for actual harm be locked.

Residents Affected - Some During an interview on 2/27/25 at 8:33 A.M., the Director of Nursing (DON) and Administrator in Training (AIT) said all medication carts, medication rooms and treatment rooms should be locked when unattended.

41105

2. The surveyor made the following observations:

- On 02/26/25 at 11:43 A.M., the surveyor observed an unlocked and unattended medication cart on the first-floor unit. The surveyor was able to open and access the cart and staff were unaware.

-On 2/25/25 at 6:49 A.M., the surveyor observed an unattended, unlocked medication cart on the second-floor unit.

During an interview on 2/26/25 at 11:44 A.M., with Nurse #1, she said that the medication cart is supposed to be locked when unattended.

During an interview on 2/27/25 at 8:33 A.M., the Director of Nursing (DON) and Administrator in Training (AIT) said all medication carts, medication rooms and treatment rooms should be locked when unattended.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 44095

Residents Affected - Few Based on record review and interview, the facility failed to maintain accurate medical records for one Resident, (#86), out of 25 sampled residents. Specifically, for Resident #86 the facility failed to maintain accurate neurological flow sheets after two unwitnessed falls.

Findings include:

Review of the facility policy titled, Neurological Signs, dated August 2015, indicated the following:

Any resident who sustains a head injury or when a head injury is questioned or suspected will have neurological signs monitored as follows:

- Every fifteen (15) minutes for one (1) hour

- Every thirty (30) minutes for one (1) hour

- Every hour for four (4) hours

- Every four (4) hours for sixteen (16) hours

- Every eight (8) hours for forty eight (48) hours

Neurological signs to be evaluated are inclusive of:

- Pupils reaction to light (PEARL)

- Level of Consciousness

- Change in mental status

- Change in speech

- Change in strength in extremities

- Vital Signs - Blood Pressure, Pulse, Respirations

- Head pain

- Nausea/vomiting

The findings of each evaluation is compared, analyzed and documented in the medical record. The physician is promptly notified of any abnormal findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Resident #86 was admitted to the facility in July 2022 with diagnoses including convulsions, repeated falls, and Wernicke's encephalopathy (confusion). Level of Harm - Minimal harm or potential for actual harm Review of the most recent Minimum Data Set (MDS) assessment, dated 2/13/25, indicated that Resident #86 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out Residents Affected - Few of 15. This MDS indicated Resident #86 required assistance with activities of daily living and he/she had two or more falls since his/her last assessment.

Review of Resident #86's fall incident reports indicated he/she had unwitnessed falls in his/her room on 1/4/25 at 10:55 P.M. and on 1/27/25 at 9:40 A.M. Both fall investigations included a photocopy of neurological checks which started at 10:55 P.M. on 1/4/25 and 3:00 P.M. on 1/27/25.

Comparative document review of both incident reports, dated 1/4/25 and 1/27/25, provided by the facility included the exact same 20 assessments for vital signs, orientation, level of consciousness, pupillary reactions, and nurse's initials. The only difference was the date and time at the top of the column for each of

the 20 neurological assessments.

During an interview on 2/27/25 at 11:15 A.M., Nurse #3 said she was the Nurse on duty when Resident #86 had a fall on 1/27/25, she reviewed the neurological sheet with the surveyor for 1/27/25. Nurse #3 said she did not document the neurological signs on the flow sheet that day. Nurse #3 said that Unit Manager #1 keeps a binder with neurological flow sheets and the Unit Manager is responsible for maintaining the documentation.

During the interview on 2/27/25 at 10:26 A.M., the surveyor and the Director of Nursing reviewed the neurological sheet documents for Resident #86's falls dated 1/4/25 and 1/27/25 and the Director of Clinical Services said that the neurological signs should be documented accurately and she was not sure why they included the exact same data.

Unit Manager #1 was unavailable for interview on 2/27/25 and staff were unable to provide the surveyor with

the binder that the neurological sheet documents were maintained.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 44095 potential for actual harm NOT CORRECTED Residents Affected - Few Based on observations and interview, the facility failed to adhere to infection control practices and standards, increasing the risk of contamination and spread of infection for residents in the facility. Specifically, two different surveyors at different times during the day shift observed Nurse #1 touch pills directly with her ungloved hands during the medication pass.

Findings include:

Review of the facility policy titled, Medications Administration - Oral, dated as revised June 2015, indicated:

3. Perform hand hygiene.

14. Do not touch the medication when opening the bottle or unit dose packaging.

1. On 3/19/25 between 7:16 A.M., through 7:24 A.M., the surveyor made a continuous observation of Nurse #1 going between two medication carts on the first-floor unit. The surveyor observed Nurse #1 preparing medications from several different prescription medication cards, over the counter bottles, and narcotics, Nurse #1 was placing medications directly into her ungloved hands. Nurse #1 placed the medications into medication cups, and Nurse #1 administered medications to two different residents.

2. On 3/19/25 at 7:40 A.M., the surveyor observed Nurse #1 preparing medications. The surveyor observed Nurse #1 open the medication cart with her bare hands contaminating them. The surveyor then observed Nurse #1 remove several pills from 3 different medication cards and place them directly into her contaminated hand (contaminating the pills) before placing them in a medication cup.

During an interview on 3/19/25 at 7:42 A.M. Nurse #1 said that she was not supposed to touch the pills with her ungloved hands.

During an interview on 3/19/25 at 11:01 A.M., the Director of Nursing said that Nurse #1 should not have poured medications directly into her hands.

36797

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 45984 potential for actual harm Based on observation and interview, the facility failed to maintain kitchen equipment in safe operating Residents Affected - Many condition. Specifically, the facility failed to ensure the dish machine was functioning properly and replace it with a new, functional dish machine.

Findings include:

During breakfast and lunch meals of the entire survey period from 2/24/25 through 2/27/25, residents were observed eating their meals out of Styrofoam take-out containers and with plastic cutlery.

During the resident screening process on 2/24/25, multiple residents from the first-floor and second-floor units reported that all of their meals have been served in Styrofoam containers and with plastic cutlery for months.

During the kitchen walk-through on 2/25/25 at 11:14 A.M., the Foodservice Director (FSD) said the dish machine has been broken and not functional for at least one month. The FSD then said there is a brand-new dishwasher in the hallway and we are waiting for it to get installed, the FSD continued to say it has been in

the hallway for a lot longer than one month. The FSD then said since the dish machine has been broken the facility has been using Styrofoam containers and plastic utensils for all meals.

During the kitchen walk-through, the surveyor observed a brand-new dish machine in the hallway still wrapped in plastic. The surveyor also observed the current dish machine not in use as it was not functioning properly.

During an interview on 2/25/25 at 11:50 A.M., the Maintenance Director said the new dish machine in the hallway got delivered around November 2024 and we have received two quotes from different companies to install it. The Maintenance Director then said he thinks it would be a one-day job for installation. The Maintenance Director said he has sent the quotes to Accounts Payable but did not hear back at first and he has needed to keep following up.

During the Resident Group Interview on 2/25/25 at 1:17 P.M., 15 out of 15 residents all said the dishwasher has been broken for months and they have been eating out of Styrofoam containers since Thanksgiving of 2024.

Review of the work order invoices dated 8/16/24, 9/4/24 and 11/6/24 indicated that the facility had an outside company come into the facility to service the dish machine that is currently broken and not in use.

Review of an invoice dated 11/22/24 indicated that the facility received an estimate for the installation of a new dish machine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 During an interview with the acting Director of Nursing, Administrator and Administrator in Training on 2/25/25 at 12:55 P.M., the Administrator said the facility has received several quotes and the dish machine Level of Harm - Minimal harm or has been getting repairs since October, but it keeps breaking down. The Administrator continued to say that potential for actual harm the residents have been continuously eating from Styrofoam containers and with plastic utensils for at least one month. Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 32 225218

F-F908

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45984 Residents Affected - Some Based on observation, record review and interview, the facility failed to protect one Resident (#92), from neglect, out of a total sample of 25 residents. Specifically, the facility neglected to schedule a follow-up appointment for over ten months when a physician's order was written for a Gastrointestinal Doctor consult to determine a possible colostomy (a surgical procedure that creates an opening (stoma) in the abdominal wall to divert stool from the colon directly into a bag or pouch) reversal procedure resulting in emotional distress.

Findings include:

Review of the facility policy titled Policy & Procedure Manual Abuse, Neglect and Exploitation, dated February 2023 indicated the following:

- It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.

- Definitions: Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional stress.

Resident #92 was admitted to the facility in January 2024 with diagnoses including traumatic brain injury, colostomy status and adult failure to thrive.

Review of Resident #92's most recent Minimum Data Set Assessment (MDS) dated [DATE REDACTED] indicated that

the Resident had a Brief Interview for Mental Status score of 12 out of 15 indicting moderate cognitive impairment. Further review of the Resident's MDS indicated that he/she has a colostomy and requires substantial/maximum assistance with toileting.

During an interview on 2/24/25 at 8:36 A.M., Resident #92 said he/she wants his/her colostomy bag removed as he/she has had it for over one year and it really bothers him/her. The surveyor observed a colostomy bag

on the lower left side of Resident #92's stomach.

During a follow-up interview with Resident #92 on 2/26/25 at 10:00 A.M., Resident #92 said he/she wants his/her colostomy reversed and it is bullshit and it should have been reversed a long time ago. He/she continued to say it smells bad and it leaks sometimes. The Resident said he/she does not want to go out in public at times because it is embarrassing, especially if it smells. The Resident continued to say that he/she has been staying in his/her room more because of the colostomy bag.

Review of Resident #92's Colostomy care plan dated 1/4/24 included interventions which indicated the following: Follow up with GI Consult if indicated. Refer to ostomy specialist as/if needed.

Review of Resident #92's progress note written by the facility's Substance Abuse Counselor indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 - Dated 2/23/24 at 2:55 P.M. - Check in with Resident on this day to learn he/she has not been seen by GI as he/she had requested in order to learn if his/her colostomy bag removed [sic]. This writer spoke with Unit Level of Harm - Actual harm Secretary to learn medical records need to be requested from an out of state hospital prior to establishing an appointment with GI near facility. Moreover, it was learned MD (medical doctor) need to order said Residents Affected - Some appointment. Unit Secretary reports herself and medical records will follow up on Resident's request.

Further review of the medical record failed to indicate any additional information regarding a follow up appointment with GI for colostomy removal was documented until 4/10/24, over a month after the Residents request on 2/23/24.

Review of Resident #92's physician's order dated 4/10/24 indicated the following: GI consult for possible colostomy reversal.

During a telephone interview on 2/26/25 at 10:19 A.M., the Medical Doctor (MD) said he saw Resident #92 two weeks ago with an ongoing plan to have a colostomy reversal. The MD said Resident #92 is in a good position to get his/her colostomy reversed but he/she needs to see a GI doctor first.

During an interview on 2/26/25 at 8:44 A.M., Unit Secretary #1 said she is in charge of making appointments and managing paperwork for residents in the facility. She continued to say she has been attempting to make

an appointment with a GI doctor but it is difficult since she does not have Resident #92's admission medical records. Unit Secretary #1 said she was unsure if the facility has obtained Resident #92's medical records yet.

During an interview on 2/26/25 at 8:50 A.M., the Medical Records Coordinator said she does not believe that Resident #92's was admitted to this facility with his/her past medical records. The Medical Records Coordinator said when a resident is not admitted with their medical records they should be obtained as soon as possible. The Medical Records Coordinator said she believes Resident #92's medical records are in the facility but she needs to find them.

During a follow-up interview on 2/26/25 at 10:15 A.M., the Medical Records Coordinator provided the surveyor with Resident #92's past medical records before he/she was admitted to the facility. The Medical Records Coordinator said she found them in a drawer in her office.

Review of Resident #92's past hospital medical records included a cover sheet which indicated the following:

- Purpose for which disclosure is to be made: Records needed to make an appointment to reverse colostomy. The cover sheet was signed and dated by Resident #92 on 8/20/24. Additionally, the coversheet had a stamped date of 8/26/24, had a date the documents were scanned on 8/27/24 and a printed dated of 8/29/24.

The facility did not request to receive Resident #92's medical records from his/her previous medical facility until seven months since the progress note was written on 2/23/24 indicating that the medical records needed to be requested prior to establishing an appointment for a colostomy reversal with a GI doctor and over five months since the physician's order for a GI consult was developed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 During a follow up interview on 2/26/25 at 10:28 A.M., just under two hours since the last interview, Unit Secretary #1 said she was able to get Resident #92 a pending appointment for a GI doctor in about 5 weeks Level of Harm - Actual harm from today, 22 minutes away from this facility. This was done after the facility provided the surveyor with Resident #92's medical records which were found in a drawer in the Medical Record Coordinator's office. Residents Affected - Some

During an interview with the Director of Nursing (DON) and Administrator in Training (AIT) on 2/27/25 at 8:33 A.M., they said referrals should be made as soon as possible but no specialty doctor would see Resident #92 until his/her medical records were available. The surveyor, DON and AIT reviewed the coversheet of Resident #92's hospital paperwork and they were not aware Resident #92's medical records were available

in August, 2024. The DON said the facility had a delay in trying to contact a GI doctor for Resident #92's colostomy reversal and the facility dropped the ball on this and it should have been done sooner if the paperwork has been available since August. The DON and AIT said it is neglectful to not follow up on this concern.

During a telephone interview with the interim Unit Secretary that was covering for Unit Secretary #1 while

she was away from the building on 2/27/25 at 9:19 A.M., the interim Unit Secretary said she was in the role from September 2024 through January 2025. The interim Unit Secretary said Medical Records had Resident #92's hospital medical records before she started covering as interim Unit Secretary, but no one told her the paperwork was in the facility until right before Christmas time.

Despite Resident #92's medical records being in the facility prior to September 2024 and despite the interim Unit Secretary being made aware that the medical records were in the facility just before Christmas time, an appointment with a GI doctor was not made until over ten months since the MD order was first written and one year since the resident first inquired about the colostomy reversal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Minimal harm or 48671 potential for actual harm Based on interviews and record review, the facility failed to implement written policies and procedures for the Residents Affected - Few investigation of allegations of abuse, protection of residents during investigations, reporting of allegations and investigative findings, and taking corrective actions to protect other residents from potential abuse for one Resident, (#55), out of a total sample of 25 residents.

Findings include:

Review of the facility policy titled Abuse, Neglect and Exploitation dated February 2023, indicated but was not limited to the following:

-It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.

-Abuse means the willful infliction of injury unreasonable confinement intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercation's Abuse also includes the deprivation of any individual, including a caretaker, of goods or services that are necessary to attain or maintain physical mental and psychosocial well-being instances of abuse of all residents irrespective of any mental or physical condition, can cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.

Prevention of Abuse, Neglect and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse neglect and misappropriation of resident property and exploitation that achieves;

B. Written procedures for investigations that include:

1. Identifying staff responsible for the investigation;

3. Investigating different types of alleged violations;

4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;

5. Focusing on the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and

6. Providing complete and thorough documentation of the investigation.

Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychological harm, as well as additional abuse, during and after the investigation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Resident #55 was admitted to the facility in October 2022 with diagnoses including major depressive disorder, anxiety, repeated falls and muscle weakness. Level of Harm - Minimal harm or potential for actual harm Review of the most recent Minimum Data Set (MDS) assessment, dated 2/14/25, indicated that Resident #55 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. The MDS Residents Affected - Few further indicated Resident #55 required supervision or touching assistance with walking.

On 2/25/25 at 8:32 A.M., the surveyor reviewed two grievance forms for Resident #55 and dated 2/24/25.

The grievance forms indicated the following:

Grievance #1 indicated: On 2/22/25 (Resident in wheelchair) and Resident #55 and (third Resident) were in

the elevator when it went to 2nd (floor). I was by the buttons when (Resident in wheelchair) told me to get out so he/she could get out. I was not in his/her way and I said you have plenty of room, then he/she told me I would be sorry when he/she rolled over my feet. I told him/her go ahead. It escalated by him/her calling me a bitch and other words. I responded by saying them back. That's when (third Resident) started laughing. (Resident in wheelchair) said he/she never liked me and I told him/her the same was mutual. (Third Resident) was blocking the elevator so I couldn't leave and go to my floor. I finally told him/her to please move and then he/she did.

Grievance #2 indicated: On 2/23/25 the security guard started accusing me of starting with (Resident in wheelchair from Grievance #1) and wouldn't listen to me. He did it so unprofessional cause other residents heard him. He told me he was going to the Substance Abuse Counselor, Administrator In Training (AIT) and Social Worker to have me thrown out cause he believes (Resident in wheelchair).

Grievance #1 and Grievance #2 was signed as received on 2/24/25 by Social Worker.

The grievance form was signed and dated 2/25/25, by the AIT, Social Worker and Unit Manager #1 as reviewed and resolved.

During an interview on 2/24/25 at 8:40 A.M., Resident #55 said he/she submitted two grievance forms to the social worker regarding an altercation with another resident in the elevator on 2/22/25. Resident #55 said the other resident threatened and rolled over his/her feet in the elevator. Resident #55 said he/she had a verbal altercation with the security guard on 2/23/25 and the security guard threatened to have him/her thrown out of the facility because he did not like the way Resident #55 was speaking to the resident in the elevator the day prior. Resident #55 said the security guard embarrassed and threatened him/her in front of other residents and said he doesn't like me. Resident #55 said he/she was upset and embarrassed by both situations and said he/she submitted a grievance form and told the Social Worker, but they won't do anything about it.

Review of Resident #55 social service progress notes did not indicate any information regarding the reported grievances.

The facility failed to provide any initial investigation into the allegations reported on 2/24/25.

Review of the Health Care Facility Report System (HCFRS) failed to indicate the facility reported the allegation to the state agency.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 32 225218 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225218 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oxford Rehabilitation & Health Care Center 689 Main Street Haverhill, MA 01830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 During an interview on 2/25/25 at 11:02 A.M., the Social Worker said she received two grievance forms from Resident #55 and said she did not feel they warranted to be reported as it was a verbal altercation between Level of Harm - Minimal harm or two residents and because she met with the security guard and gave the forms to the Administrator with the potential for actual harm plan to perform customer service education with the security guard. The surveyor reviewed both grievance forms with the Social Worker. The Social Worker said she should have read the forms entirely and said Residents Affected - Few threatening to roll over the resident's feet and threatening to have the Resident thrown out of the facility is concerning for verbal abuse.

During an interview on 2/25/25 at 12:46 P.M., with the Administrator, AIT and the Director of Nurses (DON),

the Administrator said he would expect the incidents to been investigated and reported. The AIT said she could not remember if she was notified last night or this morning and said she would expect any resident-to-resident altercations to be reported at the time of the event and investigated. The AIT said she did not receive a call over the weekend from staff regarding the resident to resident altercation. The AIT said

she would expect measures to be taken to ensure residents feel safe and said the security guard should have been placed on administrative leave pending the investigation regarding suspected verbal abuse. The DON said they do not have any investigation information at this time and said they are starting the process now.

During a follow-up interview on 2/27/25 at 10:25 A.M., the AIT said the security guard worked on 2/24/25 from 2:52 P.M., to 10:25 P.M., and said the Substance Abuse Counselor met with the security guard to go over customer service training on 2/25/25 and obtain a written statement. The AIT said she has not interviewed or met with the Security Guard as part of the investigation and that only the Substance Abuse Counselor has met with him.

During an interview on 2/27/25 at 10:27 A.M., the DON said an investigation into the allegation should have been investigated immediately on the information that was reported and the grievances should have been reviewed per policy.

Review of the Health Care Facility Reporting System (HCFRS) indicated the abuse allegation was submitted

on 2/25/25; 24 hours after the allegation was made to the Social Worker.

Refer to