Oak Hill Center for Rehabilitation and Nursing

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide the highest practical well-being by not following physician orders for daily weights for two of six residents reviewed (Residents 1 and 6).

Inspectors wroteBased on facility policy reviews, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that PRN (as needed) psychotropic medication orders were limited to 14 days for one of five residents reviewed (Resident 1); failed to provide side effect monitoring for two of five residents reviewed (Residents 3 and 128); failed to inform resident representatives of initiating psychotropic medication for one of five residents reviewed (Resident 14); and failed to ensure that the resident was free from chemical restraints imposed for the purposes of convenience for one of five residents reviewed (Resident 128).

Inspectors wroteBased on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for four of 25 residents reviewed (Residents 3, 4, 9 and 14).

Inspectors wroteBased on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to manage or prevent pain consistent with professional standards of practice and the resident's goals and preferences for one of one residents reviewed (Resident 69).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of two residents reviewed (Residents 42 and 53).

Inspectors wroteBased on review of select facility personnel documentation and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually for five of five nurse aides reviewed (Employees 3, 4, 5, 6, and 7). Findings Include: Review of personnel information revealed that Employee 3's hire date was December 7, 2021; Employee 4's hire date was February 21, 2022; Employee 5's hire date was February 6, 2024; and Employee 6's hire date was October 11, 2022; and Employee 7's hire date was March 7, 2022. Further review of personnel information for Employees 3, 4, 5, 6, and 7, failed to reveal that annual performance reviews were completed. During an interview with the Nursing Home Administrator on December 4, at 12:00 PM, he acknowledged that he had no additional documentation to provide for the selected employees. [...]

Inspectors wroteBased on facility policy review, observations, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for two of 25 residents reviewed (Residents 4 and 80).

Inspectors wroteBased on facility policy review, observations, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision and assistance devices to prevent accidents for one of five residents reviewed (Resident 4).

Inspectors wroteBased on facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure residents receive appropriate treatment and services to prevent urinary tract infections in residents with a foley catheter for one of two residents reviewed (Resident 15).

Inspectors wroteBased on review of facility policy, resident and staff interviews, and clinical record review, it was determined that the facility failed to provide routine and emergency dental services for one of one resident reviewed for dental services (Resident 81).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to provide services consistent with professional standards of practice to ensure the resident's highest level of well-being, which resulted in harm as evidenced by a delay in sending the resident to the hospital following confirmation of a femur fracture, and by failure to provide appropriate pain assessment and management for the fracture, for one of three residents reviewed (Resident 1).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to provide pharmaceutical services to meet the needs of each resident for one of three residents reviewed (Resident 1). Findings Include:Review of Resident 1's clinical record revealed diagnoses that included type II diabetes mellitus (condition characterized by high blood sugar levels due to insulin resistance and relative lack of insulin production) and muscle weakness (muscles aren't as strong as they should be). Review of Resident 1's June 2025 MAR (Medication Administration Records - forms used to document physician orders as well as when and how medications are administered to a resident) revealed an order for Ozempic subcutaneous solution (medication that mimics a hormone that lowers blood sugar) every Sunday for diabetes mellitus. [...]

Inspectors wroteBased on facility policy review, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect, which resulted in actual harm as evidenced by bilateral lobe pneumonia with small left-sided effusion (a collection of fluid around the lungs) for one of 10 residents reviewed (Resident 1).

Inspectors wroteBased on facility policy review, clinical record review, review of facility incident report, observations, and staff interviews, it was determined that the facility failed to ensure each resident receives, and the facility provides, drinks prepared in a form designed to meet individual needs for two of 10 residents reviewed (Residents 1 and 2), which resulted in actual harm to Resident 1, experiencing bilateral lobe pneumonia (an infection that inflames the lungs' air sacs) with small left-sided effusion (a collection of fluid around the lungs).

Inspectors wroteBased on clinical record review, facility dietary manual review, observations, and staff interviews, it was determined that the facility failed to provide a meal that was designed to meet the needs of residents requiring a mechanical soft meal, and failed to provide a pureed meal for one of three residents reviewed (Resident 1).

Inspectors wroteBased on resident and staff interviews, clinical record review, and document review, it was determined that the facility failed to ensure each resident is included and provided the right to participate in the person-centered care planning process for two of 32 residents reviewed (Residents 25 and 31). Findings Include: Review of the facility's New admission Introduction & Handbook, provided to each resident and/or his representative at admission read, in part, Care plans are created for each resident on admission, reviewed quarterly . You should expect to be invited to participate in Care Plan Meetings routinely. A review of Resident 25's physician's orders revealed diagnoses that included muscle weakness and chronic kidney disease (a long-term condition that occurs when the kidneys are damaged and can't filter blood properly). [...]

Inspectors wroteBased on document review, clinical record review, and staff interview, it was determined that the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage (SNF-ABN) form to two of three residents to inform those residents of items and services no longer deemed eligible for coverage under Medicare A (Residents 2 and 108). Findings Include: A review of Resident 2's clinical record revealed the last covered day of Medicare A services dated September 1, 2024. Review of the facility's provided notice, revealed the facility did not offer the Resident the SNF-ABN form as Resident 2 was planning to remain in the skilled nursing facility and receive skilled services. A review of Resident 108's clinical record revealed the last covered day of Medicare A services dated August 9, 2024. [...]

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for four of 32 residents reviewed (Residents 33, 37, 46 and 67).

Inspectors wroteBased on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for two of three residents reviewed for pressure ulcers (Resident 64 and 84).

Inspectors wroteBased on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for two of five residents reviewed for mobility (Residents 37 and 55). Findings Include: Review of facility policy, titled Restorative Nursing Services, last reviewed September 25, 2024, read, in part, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies). Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. [...]

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding, including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers, for two of three residents reviewed for tube feeding (Resident 53 and 67).

Inspectors wroteBased on policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to complete a timely assessment for trauma and then develop and implement an individualized person-centered care plan to render trauma-informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for two of 32 residents reviewed (Residents 10 and 105).

Inspectors wroteBased on observations, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to assess residents utilizing enabler bars/side rails for risk of entrapment, review the risks and benefits of the use of enabler bars/side rails with residents or their representatives, and obtain informed consent for enablers bars/side rails prior to use for two of three residents reviewed for use of enablers (Residents 84 and 105). Findings Include: [...]

Inspectors wroteBased on observation, policy review, and resident and staff interviews, it was determined that the facility failed to ensure that prescription medications and treatments were stored in locked compartments and only accessible by authorized personnel for three of 32 residents reviewed (Residents 2, 80, and 84). Findings Include: A review of facility policy, Self-Administration of Medications, revised December 2016, revealed, Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration. A review of Resident 2's clinical record revealed diagnoses that included pain and rash. An observation in Resident 2's room on November 18, 2024, at 10:42 AM, revealed a medication cup with a powder substance at the Resident's bedside. [...]

Inspectors wroteBased on observation, policy review, and staff interviews, it was determined that the facility failed to ensure enhanced barrier precautions were implemented appropriately to maintain a safe and sanitary environment that supports infection prevention and control for one of 20 residents on enhanced barrier precautions (Resident 102) and residents not on enhanced barrier precautions (Residents 41 and 66).

Inspectors wroteBased on observations, policy review, clinical record review, and staff interviews, it was determined that the facility failed to conduct regular inspections of side rails/enabler bars to identify areas of possible entrapment for two of three residents reviewed for side rails/enabler bars (Residents 43 and 105).

Inspectors wroteBased on observation, state regulation, resident and staff interviews, record review, policy review, and the facility's licensed staff scope of practice, it was determined that the facility failed to follow professional standards of practice when providing medication administration for 2 of 32 residents reviewed (Residents 31 and 84).

Inspectors wroteBased on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined the facility failed to provide respiratory care consistent with professional standards of practice for one of two residents reviewed for respiratory care (Resident 22).

Inspectors wroteBased on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards, and failed to maintain complete and accurate records related to dialysis communication for one of one resident reviewed for dialysis (Resident 326).

Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to provide or obtain dental services to meet the needs of each resident for one of one residents reviewed for dental concerns (Resident 80).

Inspectors wroteBased on clinical record and hospital record review, policy review, and staff interviews, it was determined that the facility failed to implement treatment and care in accordance with professional standards of practice, which resulted in actual harm, evidenced by a urinary tract infection and septic shock for one of three residents reviewed (Resident 1), and failed to follow physician orders for one of three residents reviewed (Resident 1).

Inspectors wroteBased on review of the clinical record and staff interview it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for two of 10 residents reviewed (Resident 3 and 10).

Inspectors wroteBased on facility policy review, nurse aide job description review, clinical record review, review of facility investigation documentation, and staff interview, it was determined that the facility failed to ensure that residents were free from neglect, which resulted in actual harm as evidenced by a right femur fracture, for one of five residents reviewed (Resident 1).

Inspectors wroteBased on facility policy review, nurse aide job description review, clinical record review, review of facility investigation documentation, and staff interview, it was determined that the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents, which resulted in a fall and actual harm as evidenced by a right femur fracture, for one of five residents reviewed (Resident 1). Findings Include: Review of facility policy, titled Activities of Daily Living (ADLs), Supporting, undated, revealed Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: .b. Mobility (transfer and ambulation, including walking) . [...]

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, and comfortable home-like environment for three of 34 resident's reviewed (Resident 2, 18, and 34).

Inspectors wroteBased on observations, review of facility policy, and resident and staff interviews, it was determined that the facility failed to provide residents access to grievance forms within reach for residents who are wheelchair-bound for one of two areas identified (Roosevelt Hall); and failed to post the required information of the Grievance Official for two of two areas identified (Jefferson Hall and Roosevelt Hall).

Inspectors wroteBased on facility policy review, employee record review, and staff interview, it was determined that the facility failed to perform criminal background checks prior to or upon hire for three of five employees reviewed (Employee 6, 7, and 8).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment was accurate for five of 29 residents reviewed (Residents 18, 22, 37, 76, and 125).

Inspectors wroteBased on observations, clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for four of 34 residents reviewed (Resident 18, 74, 99, and 100) Findings Include: Review of the facility policy, titled Care Plans, Comprehensive Person-Centered, last reviewed on August 16, 2023, revealed that assessments of resident are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of Resident 18's clinical record revealed diagnoses that included Chronic obstructive pulmonary disease (COPD - a group of lung disease that block airflow and make it difficult to breathe), Alzheimer's Disease (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and acute cough. [...]

Inspectors wroteBased on observation, policy review, staff interviews, and record review, it was determined that the facility failed to ensure that a resident with a pressure ulcer received care consistent with professional standards of practice for two of two Residents reviewed (Residents 45 and 80).

Inspectors wroteBased on observations, policy review, staff interviews, and clinical record review, it was determined the facility failed to provide oversight and monitoring of parameters of nutritional status and implementation of nutrition interventions for three of 26 residents reviewed (Residents 37, 76, and 80).

Inspectors wroteBased on review observations, policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide respiratory services for three of 32 residents reviewed (Resident 18, 37, and 328).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the licensed pharmacist's report of a medication irregularity was reviewed and acted upon for five of 26 residents reviewed for unnecessary medications (Residents 4, 22, 63, 76, and 81).

Inspectors wroteBased on clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure one of four residents reviewed were free of unnecessary psychotropic medications (Resident 42).

Inspectors wroteBased on observations, resident and staff interviews, policy review, and record review, it was determined that the facility failed to provide routine and emergency dental services for one of 29 residents reviewed (Resident 22).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety for two of three pantry refrigerators ([NAME] and Phoenix pantries).

Inspectors wroteBased on facility document review and staff interviews, it was determined that the facility failed to hold Quality Assurance Committee meetings at least quarterly for two of four quarters reviewed (First Quarter of 2023 and Second Quarter of 2023).

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to ensure implementation of an effective infection control program and ensure staff implemented infection control policies to prevent the spread of infection by wearing required PPE (personal protective equipment) and hanging correct signage for one of two residents observed (Resident 326). Findings Include: Review of facility policy, titled Monitoring Compliance with Infection Control, last revised September 2017, revealed The infection preventionist or designee shall monitor the effectiveness of our infection prevention and control work practices and protective equipment. [...]

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to ensure that residents have the right to a dignified existence for two of 34 resident's reviewed (Resident 2 and 80).

Inspectors wroteBased on record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure that resident needs were accommodated regarding call bell accessibility for two of 34 residents reviewed (Residents 18 and 34).

Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to develop a comprehensive plan of care for three of 26 residents reviewed (Residents 26, 37, and 51).

Inspectors wroteBased on clinical record review, facility policy review, and resident and staff interviews, it was determined that the facility failed to provide care and services regarding facial shaving for two of thirty-two residents reviewed (Resident 41 and 122).

Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure each resident receives proper treatment and assistive devices to maintain hearing abilities for one of 26 residents reviewed (Resident 37).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to provide restorative nursing care for range of motion exercises for one of 34 residents reviewed (Resident 100).

Inspectors wroteBased on policy review, clinical record review, observations, and staff interview, it was determined that the facility failed to ensure residents receive appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of 32 residents reviewed (Resident 327).

Inspectors wroteBased on observation, manufacturer information, facility policy review, and staff interview, it was determined that the facility failed to ensure adherence to medication expiration dates (use by dates) and failed to ensure appropriate labeling of medication when opened for one of one medication storage rooms observed ([NAME] Hall).

Inspectors wroteBased on observations, policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide adaptive feeding devices for one of 26 residents reviewed (Resident 37).

Inspectors wroteBased on review of facility policy, facility provided information, clinical records, and resident and staff interviews, it was determined that the facility failed to ensure that, in preparation for room changes, each resident received written notice, including the reason for the change, before the resident's room was changed for one of one residents reviewed (Resident 1).

Inspectors wroteBased on facility policy review, facility documentation review, clinical record review, and resident and staff interviews, it was determined the facility failed to ensure each resident is free from mental abuse for one of four residents reviewed (Resident 1). Findings Include: Review of facility policy, titled Abuse Prevention Program, with a last revised date of December 2016, revealed, in part: As part of the resident abuse prevention, the administration will: 1) Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual; and 5. Implement measures to address factors that may lead to abusive situations, for example: a. [...]