Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oxley Park Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to discard expired food in the walk-in cooler and did not ensure dietary staff wore proper hair restraints in the kitchen, potentially affecting 86 of 92 residents on an oral diet. Expired lettuce and rotting potatoes were found, and two dietary aides had hairnets that only partially covered their hair. The Dietary Manager and corporate Registered Dietician confirmed the deficiencies.
A resident with chronic obstructive pulmonary disease and other conditions was prescribed oxygen at 2 LPM, but was observed receiving 3 LPM. The DON confirmed the discrepancy, and the facility's policy requires care plans to be followed and updated as needed. The MDS Coordinator emphasized the expectation for staff to adhere to care plans.
A facility failed to revise a care plan for a resident receiving O2 therapy. The resident had a physician's order for O2 at 2 LPM, but was observed receiving 3 LPM. The resident was known to adjust the O2 rate independently, but this was not reflected in the care plan. The facility's policy requires care plans to be updated based on changing needs, which was not done in this case.
A resident with chronic health conditions was observed receiving oxygen therapy at 3 LPM, contrary to the physician's order of 2 LPM. The DON confirmed the discrepancy and acknowledged the expectation for staff to adhere to physician orders, highlighting a failure in following prescribed O2 administration.
The facility failed to ensure proper donning and doffing of PPE for Droplet Precautions in two rooms. A CNA was observed leaving a droplet precaution room with PPE on and doffing it outside the room, contrary to protocol. This was confirmed by the DON and Infection Preventionist. The facility also lacked a policy on proper PPE procedures, contributing to the deficiency.
Deficiencies in Food Storage and Personal Hygiene in Kitchen
Penalty
Summary
The facility failed to adhere to its policies regarding food storage and personal hygiene in the kitchen, which had the potential to affect 86 of 92 residents receiving an oral diet. During a tour of the kitchen, it was observed that the walk-in cooler contained expired food items, including a bag of lettuce and a box of potatoes, some of which were rotting. The Dietary Manager confirmed the presence of these expired items and acknowledged that it was the responsibility of her and her staff to label, date, and discard expired items appropriately. Additionally, the facility did not ensure that dietary staff wore proper hair restraints while in the food preparation area. Observations revealed that two dietary aides had hairnets that only partially covered their hair, leaving parts of their hair exposed. The corporate Registered Dietician and the Dietary Manager confirmed that all kitchen staff should have their entire head of hair covered while handling and serving food, and they addressed the issue with the staff members involved.
Failure to Follow Oxygen Care Plan for Resident
Penalty
Summary
The facility failed to adhere to the care plan for a resident, identified as R184, specifically regarding the prescribed rate of oxygen. The resident had a medical history that included chronic obstructive pulmonary disease, atrial fibrillation, heart failure, and a dependence on supplemental oxygen. The physician's order, dated January 10, 2025, specified that the resident should receive oxygen via nasal cannula at a rate of 2 liters per minute every 8 hours. However, during an observation on January 30, 2025, the resident was found to be receiving oxygen at a rate of 3 liters per minute. The Director of Nursing confirmed the discrepancy between the observed oxygen rate and the physician's order. The facility's policy requires that each patient's care plan be reviewed and updated based on ongoing clinical assessments and changes in the patient's condition. Despite this policy, the staff did not follow the care plan as prescribed, leading to the deficiency. The Minimum Data Set Coordinator also expressed that staff are expected to adhere to the care plan, highlighting a lapse in following established procedures.
Failure to Revise Care Plan for Oxygen Use
Penalty
Summary
The facility failed to revise a care plan related to oxygen (O2) use for a resident receiving O2 therapy. The resident, identified as R184, had a physician's order for O2 via nasal cannula at 2 liters per minute (LPM) every 8 hours. However, during an observation, the Director of Nursing (DON) found the resident receiving O2 at a rate of 3 LPM. The DON confirmed that the resident was known to adjust the O2 rate independently, but this behavior was not reflected in the care plan. The care plan, initiated on the same date as the physician's order, did not include interventions for monitoring or addressing the resident's tendency to change the O2 flow rate. The facility's policy requires that care plans be reviewed and revised based on changing needs and interventions. Despite this, the care plan for R184 was not updated to include the resident's behavior of adjusting the O2 rate, nor were there any interventions added to address this issue. The DON acknowledged that staff should be checking the O2 more frequently due to the resident's known behavior. The Minimum Data Set (MDS) Coordinator confirmed that the care plan should be individualized to fit the resident's ongoing needs, which was not done in this case.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to ensure that the physician's order for oxygen (O2) administration was followed for a resident. The resident, who had diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, heart failure, and dependence on supplemental O2, had a physician's order for O2 via nasal cannula at 2 liters per minute (LPM) every 8 hours. However, observations on multiple occasions revealed the resident receiving O2 at 3 LPM instead of the ordered 2 LPM. The Director of Nursing (DON) confirmed the discrepancy between the physician's order and the actual O2 administration, acknowledging that the expectation was for staff to follow physician orders. This failure had the potential to place the resident at risk for medical complications related to O2 not being administered as ordered.
Improper PPE Doffing for Droplet Precautions
Penalty
Summary
The facility failed to ensure proper donning and doffing of Personal Protective Equipment (PPE) for Droplet Precautions in two of twelve rooms, as observed during a survey. A Certified Nurse Assistant (CNA) was seen leaving a droplet precaution room while still wearing gloves, a face shield, a mask, and a gown, and subsequently doffing the PPE outside the room instead of inside, as required. This practice was confirmed through interviews with the CNA, the Director of Nursing (DON), and the Infection Preventionist, who all acknowledged the improper procedure. Additionally, the facility lacked a specific policy addressing the correct procedures for donning and doffing PPE, which contributed to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lyons
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oaks - Bethany Skilled Nursing, The | 2.2 mi | — | 3 | 0 |
| Meadows Park Health And Rehabilitation | 5.5 mi | — | 0 | 0 |
| Tattnall Healthcare Center | 16 mi | — | 0 | 0 |
| Treutlen County Health And Rehabilitation | 18.7 mi | — | 3 | 0 |
| Glenwood Health And Rehabilitation | 19.7 mi | — | 22 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.