Oak Hill Health & Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure treatment and care was provided to all facility residents for physician prescribed medications for 2 of 4 residents, Resident #1 and #4, reviewed for medication administration.

Inspectors wroteBased on interview and record review, the facility failed to document unavailable medications and notification to physicians of missed doses of ordered medications for 2 (Resident #1 and Resident #4) of 4 residents reviewed for medication administration.

Inspectors wroteBased on interview and record review the facility failed to ensure Preadmission Screening and Resident Reviews (PASRR) were accurately completed for 7 of 7 residents, Residents #9, #15, #23, #28, #31, #44, #59, reviewed for mood and behavior.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatment and care was provided for intravenous (IV) dressing changes for 2 of 4 residents, Residents #195 and #444, reviewed for IV catheters and infusions, and failed to ensure medication management for 1 of 6 residents, Resident #55, reviewed for medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were securely stored when unattended and failed to date and label intravenous (IV) medication infusion bags and tubing.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure foods and drinks were served at a safe and appetizing temperature.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food was stored in accordance with professional standards in the kitchen walk-in cooler and walk-in freezer and in the second floor nourishment freezer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete and accurately documented medical records for 1 of 4 residents, Resident #195, reviewed for central catheters and 2 of 6 residents, Resident #5 and #13, reviewed for medication management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the possible spread of infection when not following infection control standards to wear appropriate personal protective equipment for 3 of 5 residents, Resident #195, #444, and #499, reviewed for enhanced barrier precautions, and failed to store respiratory equipment when not in use for 1 of 2 residents, Resident #5, reviewed for respiratory services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were kept secured in the facility in 2 of 4 residents rooms observed, Resident #2 and Resident #4 (Photographic evidence obtained).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medication orders were obtained according to professional standard of quality for 1 of 6 residents reviewed for unnecessary medications, Resident #80.

Inspectors wrote2. Review of Resident #18's admission record showed the resident was most recently admitted on [DATE] with the diagnoses that included chronic obstructive pulmonary disease, hypertensive heart disease, and chronic diastolic (congestive) heart failure. During an observation on 3/11/2024 at 1:11 PM, Resident #18 was receiving oxygen at 4 liters per minute via nasal cannula (NC). During an observation on 3/12/2024 at 9:42 AM, Resident #18 was receiving oxygen at 4 liters per minute via NC. During an interview on 3/13/2024 at 8:44 AM, Staff B, LPN, stated, There is no order for the oxygen. The oxygen should be set at 4 liters via Nasal Canula. During an interview on 3/13/2024 at 11:15 AM, the Director of Nursing stated, There are no orders for oxygen administration and the orders should have been written. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were assessed by registered dietician and measures were put into place to maintain acceptable parameters of nutritional status to prevent weight loss for 1 of 4 residents reviewed for nutritional status, Resident #25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received respiratory care consistent with professional standards of practice for 1 of 4 residents reviewed for respiratory care, Resident #19.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were from unnecessary medications for 1 of 3 residents reviewed for urinary tract infections, Resident #209.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were securely stored in 1 of 6 residential halls, Hall 500.

Inspectors wroteBased on observation, interview and record review, the facility failed to adhere to professional standards of infection Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration to help prevent the possible transmission of infections and communicable diseases during 3 of 7 observations of medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 2 residents who were fed by enteral means, Residents #181 and #183, received properly labeled enteral feeding bag with date, time, and initials of nurse.

Inspectors wrote3. Review of Resident #5's medical records revealed the resident was admitted on [DATE] with the diagnoses including anxiety disorder, major depressive disorder, and dementia. Review of Resident #5's physician orders dated 8/13/2022 reads, Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for anxiety . Quetiapine Fumarate Oral Tablet 50 MG Give 1 tablet by mouth at bedtime for behaviors . Sertraline HCl Oral Tablet 50 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for anxiety. Review of Resident #5's physician orders dated 8/17/2022 reads, Memantine HCl Oral Tablet 10 MG (Memantine HCl) Give 1 mg by mouth every 12 hours for Agitation . Rivastigmine Tartrate Oral Capsule 1.5 MG (Rivastigmine Tartrate) Give 1 capsule by mouth every 12 hours for Agitation. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food was stored in accordance with professional standards in the walk-in cooler and walk-in freezer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received services for activities of daily living (ADL) needs specific to bathing and personal hygiene for 1 of 3 reviewed residents, Resident #64, in a total sample of 39 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 2 of 3 residents reviewed, Residents #32 and #182, in a total sample of 39 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 2 of 3 residents reviewed for respiratory care, Residents #54 and #1, in a total sample of 39 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the expiration date when applicable.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the garbage and refuse were disposed of properly.