Inspection Reports for Oxford Nursing Home
144 So Oxford St, Brooklyn, NY, 11217
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
135% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Sep 11, 2025
Visit Reason
One standard health citation for reporting of alleged violations with level 2 severity and pattern scope.
Findings
One standard health citation for reporting of alleged violations with level 2 severity and pattern scope.
Deficiencies (1)
Reporting of alleged violations
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Sep 11, 2025
Visit Reason
The abbreviated survey was conducted to evaluate the facility's compliance with reporting requirements related to suspected abuse, neglect, exploitation, or mistreatment of residents.
Complaint Details
The survey was complaint-related, triggered by allegations involving abuse of two residents. The findings showed the facility did not report the allegations within the required 2-hour or 24-hour timeframes. Resident #1 alleged rough handling during a transfer on 05/27/2025, reported to the state on 05/28/2025. Resident #2's Next of Kin reported staff shoved the resident on 06/23/2025, reported on 06/24/2025. Both residents were assessed with no visible injuries.
Findings
The facility failed to ensure timely reporting of alleged violations involving abuse or neglect to the appropriate authorities within the required timeframes. Specifically, two incidents involving Resident #1 and Resident #2 were reported late to the New York Department of Health.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Residents sampled for abuse: 4
Residents with substantiated late reporting: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #1 | Documented Resident #1's allegation of abuse and reported it to the Director of Nursing | |
| Registered Nurse Supervisor #2 | Documented Resident #2's Next of Kin report of abuse | |
| Director of Nursing | Director of Nursing | Responsible for reporting abuse incidents to the New York State Department of Health |
| Administrator | Administrator | Stated responsibility of Director of Nursing for timely reporting of incidents |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Sep 9, 2025
Visit Reason
Three standard health citations related to activities meeting resident interests, encoding/transmitting resident assessments, and quarterly assessments with level 1 and 2 severities.
Findings
Three standard health citations related to activities meeting resident interests, encoding/transmitting resident assessments, and quarterly assessments with level 1 and 2 severities.
Deficiencies (3)
Activities meet interest/needs each resident
Encoding/transmitting resident assessments
Qrtly assessment at least every 3 months
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Sep 9, 2025
Visit Reason
The inspection was conducted as a Recertification survey to assess compliance with regulatory requirements including timely submission of Minimum Data Set (MDS) assessments and provision of resident activities.
Findings
The facility failed to submit Minimum Data Set assessments within required timeframes for 43 of 54 residents reviewed, and did not provide an ongoing activity program that met the interests and cultural preferences of Resident #44, who was Cantonese-speaking and lacked access to preferred language television programming or alternative activities.
Deficiencies (2)
Failure to submit Minimum Data Set (MDS) 3.0 comprehensive and quarterly assessments within 14 calendar days after completion for 43 of 54 residents reviewed.
Failure to provide activities that meet the interests and cultural preferences of Resident #44, including lack of Cantonese language television programming and alternative activities.
Report Facts
Residents reviewed for MDS submission: 54
Residents with late MDS submissions: 43
Residents sampled for activities review: 38
Residents cited for activities deficiency: 1
Television channels provided: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minimum Data Set Coordinator | Interviewed regarding responsibilities and late submission of assessments | |
| Administrator | Interviewed regarding awareness of late MDS submissions | |
| Certified Nursing Assistant #3 | Interviewed about Resident #44's alertness, language, and activity engagement | |
| Recreation Aide #1 | Conducted activity assessment for Resident #44 and interviewed about activity preferences and language barriers | |
| Recreation Director | Interviewed about availability of language-specific programming and devices for residents |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 11
Date: Sep 26, 2023
Visit Reason
Multiple standard health and life safety code citations with level 2 severity, many corrected as of late 2023.
Findings
Multiple standard health and life safety code citations with level 2 severity, many corrected as of late 2023.
Deficiencies (11)
Baseline care plan
Infection prevention & control
Label/store drugs and biologicals
Menus meet resident nds/prep in adv/followed
Reporting of alleged violations
Right to participate in planning care
Subsistence needs for staff and patients
Electrical systems - essential electric syste
Fire alarm system - testing and maintenance
Gas equipment - cylinder and container storag
Vertical openings - enclosure
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 26, 2023
Visit Reason
The inspection was conducted as a recertification and complaint survey to investigate a complaint regarding the facility's failure to timely report an alleged resident-to-resident physical abuse incident to the New York State Department of Health.
Complaint Details
The complaint investigation found that the facility did not report a resident-to-resident physical abuse incident within the required timely manner. The incident involved Resident #161 being hit in the face by Resident #182's cane on 07/27/2023. The facility reported the incident to NYSDOH on 08/07/2023. The Director of Nursing and Administrator confirmed the delay was due to waiting for a full investigation before reporting. There was no imminent safety concern and Resident #161 did not sustain major injury.
Findings
The facility failed to report a resident-to-resident physical abuse incident that occurred on 07/27/2023 to the NYSDOH until 08/07/2023, which was more than two hours after the occurrence. The investigation was completed on 08/03/2023, and the facility staff and administration acknowledged the delay in reporting due to waiting for a full investigation before notifying authorities.
Deficiencies (1)
Failure to timely report suspected resident-to-resident physical abuse to the New York State Department of Health.
Report Facts
Residents sampled: 38
Date of incident: Jul 27, 2023
Date of report to NYSDOH: Aug 7, 2023
Date of investigation completion: Aug 3, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DNS) | Interviewed regarding the incident and investigation |
| Administrator | Administrator | Interviewed regarding reporting procedures and knowledge of abuse reporting requirements |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Sep 26, 2023
Visit Reason
The inspection was a Recertification Survey conducted from 09/20/2023 through 09/26/2023 to assess compliance with regulatory requirements for Oxford Nursing Home.
Findings
The facility was found deficient in multiple areas including failure to include residents and their representatives in care planning, untimely completion and distribution of baseline care plans, improper medication labeling and storage, failure to follow menus as prescribed, and inadequate infection control practices during meal service.
Deficiencies (5)
Failure to facilitate inclusion of resident and representative in comprehensive care planning process for 1 of 38 sampled residents.
Baseline care plans were not completed timely and residents and representatives were not provided written summaries for 3 of 38 sampled residents.
Drugs and biologicals were not labeled or stored in locked compartments on 3 of 5 floors, including unlabeled eye drops and unsecured intravenous antibiotics.
Menus were not followed for 1 of 38 sampled residents; resident did not receive lunch items listed on tray ticket.
Infection control practices were not maintained; CNA did not perform hand hygiene between serving residents during meal service on 2nd floor.
Report Facts
Residents sampled: 38
Residents affected: 1
Residents affected: 3
Floors affected: 3
Residents affected: 1
Units observed: 6
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #10's Health Care Proxy | Named in deficiency for not being invited to care planning meeting | |
| Social Worker | Social Worker (SW) | Interviewed regarding care planning invitation process |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care planning invitations and medication storage |
| Registered Dietician | Registered Dietician (RD) #1 | Interviewed regarding baseline care plan completion and menu compliance |
| Registered Nurse | Registered Nurse (RN) #1 | Interviewed regarding baseline care plan creation and medication labeling |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) #2 | Interviewed regarding medication storage |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) #4 | Observed and interviewed regarding infection control practices during meal service |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) #5 | Interviewed regarding infection control practices during meal service |
| Food Service Manager | Food Service Manager (FSM) | Interviewed regarding menu preparation and substitutions |
| Food Service Supervisor | Food Service Supervisor (FSS) | Interviewed regarding meal service process |
| Director of Social Services | Director of Social Services (DSS) | Interviewed regarding baseline care plan distribution |
| MDS Coordinator | MDS Coordinator (MDSC) | Interviewed regarding baseline care plan creation and distribution |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Jul 13, 2021
Visit Reason
The inspection was a Recertification Survey to assess compliance with regulatory requirements for Oxford Nursing Home.
Findings
The survey identified multiple deficiencies including failure to maintain resident confidentiality, inadequate housekeeping and maintenance, improper use of physical restraints, lack of resident participation in care planning, insufficient activities for residents, expired and improperly labeled medications, unsafe food handling and storage, infection control lapses, unsafe and unsanitary environment conditions, and ineffective pest control.
Deficiencies (12)
Facility did not ensure residents' personal medical information was kept confidential; notices with room numbers and infection types were posted publicly.
Facility did not maintain a safe, clean, comfortable environment; observed corroded radiator covers, unpainted areas, mismatched paint, water damage, and other maintenance issues in multiple resident rooms and staff bathrooms.
Facility failed to ensure residents were free from physical restraints not medically necessary; wedge pillows used as restraints without orders or care plans for multiple residents.
Facility did not ensure residents and their representatives were involved in care planning meetings; multiple residents reported not being invited or notified.
Facility failed to provide ongoing activities meeting resident preferences and needs; one resident requiring 1:1 activities did not receive adequate stimulation or engagement.
Facility did not ensure timely removal of expired medications; multiple expired medications found in medication storage room.
Facility did not ensure all medications and biologicals were properly labeled and stored; insulin vials and pens lacked open/discard dates, and some medications lacked resident identification labels.
Facility did not maintain proper food safety; potentially hazardous cold foods such as ham and cheese sandwiches were held at unsafe temperatures above 41°F during preparation and service.
Facility did not ensure residents received food accommodating allergies, intolerances, and preferences; residents received foods contrary to their documented preferences.
Facility failed to maintain infection control practices; blood pressure cuffs were not cleaned between residents, housekeeping staff improperly transported garbage, and PPE was not properly used when entering isolation rooms.
Facility did not maintain a safe, clean, and comfortable environment; staff and resident bathrooms on multiple units had peeling paint, rust, leaks, broken tiles, and other disrepair.
Facility did not maintain an effective pest control program; live rodent observed in basement dining area and live roach observed in nurse's station on 5th floor.
Report Facts
Residents reviewed for Physical Restraints: 3
Residents reviewed for Participation in Care Planning: 6
Residents reviewed for Activities: 5
Residents reviewed for Food: 7
Expired medications observed: 5
Roaches found: 815
Mice found: 509
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed about infection control and maintenance reporting |
| RN #3 | Registered Nurse | Interviewed about infection control and physical restraint use |
| Director of Nursing | Director of Nursing | Interviewed about infection control, medication storage, physical restraints, and maintenance |
| Administrator | Administrator | Interviewed about infection control, maintenance, and activities |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Interviewed about resident behavior and activities |
| Recreation Director | Recreation Director | Interviewed about activities provided to Resident #44 |
| Pharmacy Consultant | Pharmacy Consultant | Interviewed about medication audits and expired medications |
| Food Service Manager | Food Service Manager | Interviewed about food service and food safety |
| Director of Housekeeping/Maintenance | Director of Housekeeping/Maintenance | Interviewed about housekeeping practices and pest control |
| Pest Control Contractor | Pest Control Contractor | Interviewed about pest control program and findings |
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