Cycle 1
Health 2025-11-21 · Fire 2024-07-03
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Oxford, NC
Oxford Health and Rehabilitation Center
2-star overall rating with 3-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
500 Prospect Avenue, Oxford, NC
(919) 693-1531
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
156
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
1988-12-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
59 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.31
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.12
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.38
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.78
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.31
CMS adjusted RN staffing hours
Adjusted total hours
3.34
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,888
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9952
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.11
Baseline 19.59% · Performance 18.14% · Measure score 7.11 · Achievement 7.11 · Improvement 5.17
Healthcare-associated infections
5.57
Baseline 7.14% · Performance 6.17% · Measure score 5.57 · Achievement 5.57 · Improvement 4.01
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0
Baseline 2.88 hours · Performance 2.70 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.63% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 76 · Observed rate 14.47% · Lower 95% interval 7.97% |
| Discharge to community | 34.99% |
50.57%
15.6 pts worse
|
Worse than the National Rate · Eligible stays 72 · Observed rate 23.61% · Lower 95% interval 24.2% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 114 · Denominator 114 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 114 |
| Discharge self-care score | 33.33% |
53.69%
20.4 pts worse
|
Numerator 22 · Denominator 66 |
| Discharge mobility score | 30.3% |
50.94%
20.6 pts worse
|
Numerator 20 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 7.02% |
2.29%
4.7 pts worse
|
Numerator 8 · Denominator 114 · Adjusted rate 6.22% |
| Healthcare-associated infections requiring hospitalization | 6.17% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 3.77% · Lower 95% interval 3.21% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 122 |
| Staff flu vaccination coverage | 48.41% |
42%
6.4 pts better
|
Numerator 61 · Denominator 126 |
| Discharge function score | 36.36% |
56.45%
20.1 pts worse
|
Numerator 24 · Denominator 66 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 41 · Denominator 41 |
| Transfer of health information to patient | 90.32% |
96.28%
6 pts worse
|
Numerator 28 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 12.5% |
25.2%
12.7 pts worse
|
Numerator 10 · Denominator 80 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
1.8
0.9 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.2% |
91.5%
7.3 pts worse
|
93.4%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 63.6% · Q2 78.6% · Q3 93.1% · Q4 100.0% · 4Q avg 84.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.9% |
94.1%
4.2 pts worse
|
95.5%
5.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.6%
1.1 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.8% · Q3 3.1% · Q4 5.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.2% |
4.8%
4.4 pts worse
|
11.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.7% · Q3 10.7% · Q4 19.5% · 4Q avg 9.2% |
| Percentage of long-stay residents who lose too much weight | 15.6% |
7.2%
8.4 pts worse
|
5.4%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 13.6% · Q3 11.7% · Q4 19.8% · 4Q avg 15.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.7% |
21.6%
4.9 pts better
|
19.6%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 19.7% · Q3 18.0% · Q4 14.4% · 4Q avg 16.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 34.2% |
15.0%
19.2 pts worse
|
16.7%
17.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.7% · Q2 37.1% · Q3 34.2% · Q4 29.1% · 4Q avg 34.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.1% |
21.5%
10.4 pts better
|
16.3%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.8% · Q2 10.6% · Q3 13.0% · Q4 4.5% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.0% |
16.8%
4.8 pts better
|
14.9%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.7% · Q2 10.8% · Q3 14.2% · Q4 5.0% · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.5% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
2.6%
2.2 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.4% |
21.2%
2.2 pts worse
|
19.8%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 22.5% · Q3 26.2% · Q4 25.2% · 4Q avg 23.4% |
| Percentage of long-stay residents with pressure ulcers | 9.9% |
6.0%
3.9 pts worse
|
5.1%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 12.4% · Q3 11.6% · Q4 5.9% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.6% |
79.9%
8.3 pts worse
|
81.7%
10.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 58.1% · Q2 63.9% · Q3 75.9% · Q4 90.1% · 4Q avg 71.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.4% |
13.2%
4.2 pts worse
|
12.0%
5.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.4% · Observed 19.8% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.5% |
1.5%
2 pts worse
|
1.6%
1.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 4.2% · Q3 6.6% · Q4 2.4% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 66.7% |
78.1%
11.4 pts worse
|
79.7%
13 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 66.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
22.9%
2.1 pts better
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 22.8% · Expected 26.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-03 · Fire 2023-05-18
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2023-05-18 · Fire 2022-02-10
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-03
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-07-31
F · Potential for more than minimal harm
2024-07-03
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-07-03
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-07-03
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-07-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-07-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-28
F · Potential for more than minimal harm
2023-05-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-15
F · Potential for more than minimal harm
2023-05-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-15
E · Potential for more than minimal harm
2023-05-18
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-05-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-05-18
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-05-18
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-05-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-05-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-08-15
F · Potential for more than minimal harm
2022-02-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-03-30
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-11-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-11
E · Potential for more than minimal harm
2025-11-21
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2026-01-11
D · Potential for more than minimal harm
2025-11-21
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2026-01-11
D · Potential for more than minimal harm
2025-11-21
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-10-25
D · Potential for more than minimal harm
2025-11-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-01-11
D · Potential for more than minimal harm
2025-11-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-11
D · Potential for more than minimal harm
2025-11-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-11
D · Potential for more than minimal harm
2025-11-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-01-11
F · Potential for more than minimal harm
2024-07-03
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-07-31
E · Potential for more than minimal harm
2024-07-03
F761 · Pharmacy Service Deficiencies
Health
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 locked, compartments for controlled drugs.
Corrected 2024-07-31
E · Potential for more than minimal harm
2024-07-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-07-03
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-07-03
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-07-31
C · Minimal harm
2024-07-03
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-07-31
E · Potential for more than minimal harm
2023-05-18
F761 · Pharmacy Service Deficiencies
Health
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 locked, compartments for controlled drugs.
Corrected 2023-06-13
D · Potential for more than minimal harm
2023-05-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-06-13
D · Potential for more than minimal harm
2023-05-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-13
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Brantwood Nh & Retirement Center
Oxford, NC
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Senior Citizens Home
Henderson, NC
2-star overall rating with 2-star inspections with $55,760 in total fines with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Kerr Lake Nursing and Rehabilitation Center
Henderson, NC
3-star overall rating with 3-star inspections with $32,269 in total fines with 2 recent health deficiencies
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