Oxford Health And Rehabilitation Center

Federal health inspectors cited Oxford Health and Rehabilitation Center in Oxford, NC for a deficiency under regulatory tag F-F0580 during a complaint investigation conducted on 2025-11-21.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of Oxford Health and Rehabilitation Center.

Correction Status: Deficient, Provider has no plan of correction.

F 0582

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, and staff and Durable Power of Attorney interviews, the facility failed to convey (transfer) funds within 30 days of discharge from the facility to the Durable Power of Attorney for 1 of 3 residents reviewed for refund of deposit (Resident #165).Findings included:Resident #165 was admitted to the facility

on [DATE REDACTED]. The resident had a planned discharge to another skilled nursing facility on 4/11/25.A review of

the discharge tracking MDS dated [DATE REDACTED] revealed Resident #165 had a planned discharge to another facility on 4/11/25.On 11/18/25 at 1:03 PM an interview via telephone with Resident #165's Durable Power of Attorney (DPOA) occurred. The DPOA explained the resident initially paid privately for care at the facility.

Resident #165 was discharged to another skilled nursing facility on 4/11/25 and was owed a refund of approximately $1700. The DPOA revealed she had been in contact with the facility's Business Office Manager (BOM) the week of 4/11/25 and was told she would receive a refund but still had not received the refund as of 11/18/25. The DPOA expressed she was mad she had to wait so long for the reimbursement.

The DPOA voiced, they [the facility] were giving her the run around.The BOM was interviewed on 11/19/25 at 11:04 AM. The BOM indicated the DPOA had not yet received a refund of $1730 for two reasons. First, at

the time of discharge Resident #165 had outstanding insurance claims pending and it was the facility's policy to collect all outstanding insurance payments before a refund could be issued. The pending insurance claims were completed during the week of 6/27/25 and a refund check was issued on 7/9/25.

Second, the refund check was returned to the facility during the week of 8/11/25 due to an error in the mailing address. The BOM indicated she had not yet requested a new refund to be sent with the corrected address due to an oversight and she should have notified the corporate office of the mailing address error and requested another refund. On 11/19/25 at 11:27 AM a telephone interview occurred with the Director of [NAME] Office Services. The Director of [NAME] Services indicated that it was the facility policy for refunds to be provided by the 30th day of discharge and when all insurance payments had been received. The Director of [NAME] Services confirmed the last insurance payment was received by the facility on 6/27/25 and the BOM notified the corporate office on 7/9/25 of the refund request. The Director of [NAME] Services further revealed that he did not become aware that the initial refund check had been returned due to an error in the mailing address until sometime this month and had not yet received additional mailing address information from the BOM and therefore had not mailed a second refund check. An interview was conducted with the Administrator on 11/20/25 at 2:23 PM. The Administrator indicated that the resident/resident representative should have received a refund per the regulation.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oxford Health and Rehabilitation Center

500 Prospect Avenue Oxford, NC 27565

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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Validation of the corrective action plan was completed on 11/20/25: The validation included staff interviews and a review of the in-service education provided to the licensed nurses on the subject of Handling Narcotic Misappropriation with education on the follow-up of incidents. The in-service records confirmed that all nurses scheduled to work during the 4-day survey had completed this education. An observation was also conducted of the process employed by nursing staff to verify the narcotic count during shift change. A

review of the facility's monitoring tool revealed audits were initiated on 10/20/25 and continued in accordance with the corrective action plan. The facility's completion date of 10/25/25 was validated on 11/20/25.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oxford Health and Rehabilitation Center

500 Prospect Avenue Oxford, NC 27565

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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

never smoke in his room and he kept his smoking materials in fear they would go missing. An interview was conducted on 11/18/2025 at 12:36 PM with Nurse #1. Nurse #1 stated she kept Resident #50's smoking materials in the nurse's medication cart and they were labeled with his name. She stated Resident #50's family members also brought him smoking material and sometimes he will have them in his possession.

She further revealed Resident #50 does not need supervision when smoking. On 11/19/2025 at 12:57 PM

in an interview with the Director of Nursing (DON), she explained smoking assessments were completed on admission, quarterly, and for a change in condition. She stated nurses were responsible for conducting smoking assessments, and Resident #50 should have had a smoking assessment conducted in September

1. 2025. The DON stated interventions for a smoker were based on the assessment performed whether they

are independent or supervised. If a resident needed a smoking apron, a staff member for supervision, were some of the interventions the DON was referencing. She stated the facility had staff to assist with supervised smokers and ensure interventions were followed. The DON confirmed independent residents who smoke may go out to the smoking area at their leisure. The DON could not explain why the assessment for Resident #50 was inaccurate or not completed quarterly. The DON stated the nurses were notified when a smoking assessment was due for a resident in the electronic medical record.An interview was conducted on 11/19/2025 at 10:01 AM with the Administrator. She stated the window in her office that views the smoking area and she could view all the residents who are smoking in the smoking area. She stated she had viewed Resident #50 smoking from her office and believed the smoking assessment dated [DATE REDACTED] was not completed accurately for Resident #50. The Administrator stated Resident #50 was a safe smoker and she had observed him many times but had not completed a formal smoking assessment. She further stated Nurse #4 informed her she was confused with the verbiage of the smoking assessment and

the smoking assessment for Resident #50 was inaccurate. The Administrator stated residents who were assessed as safe independent smokers were allowed to possess their own smoking materials. She further explained residents who required supervision with smoking, their smoking materials were kept with the nurse on their unit. The Administrator confirmed smoking assessments were completed for residents upon admission, quarterly and as needed for the purpose of a safe smoking evaluation. She further revealed the nurses were responsible for completing the assessment based on an alert in the electronic medical record for the resident.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oxford Health and Rehabilitation Center

500 Prospect Avenue Oxford, NC 27565

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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

nurse (Nurse #6) should have verified the start date and time and changed the automatic response to begin

on 12/10/24 at 8:00 PM. The EMR system scheduled the medications to begin at 8:00 AM on 12/11/24. She verified Resident #174 should have received his evening medications per the physician's orders. She stated

the transcribing nurse (Nurse #6) should have reviewed Resident #174's medications to determine if he had any upcoming medications due and then obtain them from the Pyxis system if they were available. If the medications were not available, the nurse should call pharmacy to have the medications sent. The DON also stated in this case the medications were available in the Pyxis system. An interview was conducted on 11/19/2025 at 11:26 AM with Physician #1. He stated he did not recall Resident #174 however he would expect medications to be administered on date of admission if they were scheduled. Physician #1 explained although there was the potential for negative outcomes to occur, none resulted due to Resident #174's medications not being administered at 8:00 PM and 9:00 PM on 12/10/24.

Event ID:

Facility ID:

If continuation sheet