Oak Hill Rehabilitation and Nursing Care Center

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 3/17/2025-3/19/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 main kitchen. Specifically, in the main kitchen food was not properly stored or labeled; there were multiple unclean and uncleanable surfaces; and food products and equipment in the storage areas were below wastewater lines.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 3/17/2025-3/19/2025, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections including legionella (a type of bacteria found in water which can cause Legionnaires' disease); and did not handle, store, process, and transport linens and laundry in accordance with accepted standards to produce hygienically clean laundry and prevent the spread of infection for 1 of 1 laundry room reviewed. Specifically, there was no facility assessment for legionella, annual sampling for legionella was not conducted in 2024, legionella sampling completed in 2023 and 2025 did not include sampled sites in the water management plan; [...]

Inspectors wroteBased on observations and interviews during the recertification and abbreviated (NY00371301) surveys conducted 3/17/2025-3/19/2025, the facility did not provide each resident with a nourishing, palatable, well-balanced diet that met their daily nutritional needs for 2 of 2 meals (the 3/17/2025 and 3/18/2025 lunch meals) reviewed. Specifically, the 3/17/2025 lunch meal had a cold dessert served outside the appropriate temperature range, food items were missing, the texture of food items were not palatable, and the meal ticket directions were not followed; and the 3/18/2025 lunch meal tray had an item missing from the tray.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 3/17/2025-3/19/2025, the facility did not ensure garbage and refuse was disposed of properly. Specifically, facility garbage areas were not maintained to prevent attraction and harborage of pests.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 3/17/2025-3/19/2025, the facility did not ensure the resident environment remained free of accident hazards for 1 of 3 residents (Resident #40) reviewed. Specifically, Resident #40 had medication at their bedside not ordered by the medical provider and the resident was not evaluated for the ability to self-administer medications.

Inspectors wroteBased on observations and interviews during the recertification survey conducted 3/17/2025-3/19/2025, the facility did not ensure drugs and biologicals were stored in accordance with professional principles to include storage in a locked compartment under proper temperature control and permitted only authorized personnel access for 1 of 1 storage area (first-floor clean utility room) reviewed. Specifically, the first floor medication refrigerator was unlocked and stored in an accessible clean linen room; and the medication refrigerator contained several temperature sensitive medications and was out of proper temperature range.

Inspectors wroteBased on observation, record review, and interviews during the abbreviated survey (NY00356309) the facility did not ensure a resident who was fed by enteral means (delivery of nutrients through a feeding tube directly into the stomach) received the appropriate treatment and services to prevent complications for 3 of 3 residents (Residents #1, #2, and #3). Specifically, Residents #1, #2 and #3 received their nutritional needs through tube feedings and tube feeding documentation was unclear as to the duration and amount of feeding administered and received.

Inspectors wroteBased on record review and interviews during the abbreviated survey (NY00356309), the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 received their nutritional needs through a tube feeding (delivery of nutrients through a feeding tube placed directly into the stomach). The feeding tube became dislodged, and the resident was not assessed timely by a qualified professional.

Inspectors wroteBased on observation, interview, and record review during the abbreviated survey (NY00332366) conducted on 3/8/2024, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service in the facility's kitchen. Specifically, food was not properly heated for service, food products were left uncovered in the kitchen, and numerous unclean and uncleanable surfaces were present in the food service and storage areas.

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00283542) the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #2) reviewed. Specifically, Resident #2 was admitted to the facility with a diagnosis of septic shock (severe widespread infection) with recommendations to begin preventative antibiotics after completion of the current antibiotic course and to follow-up with urology. There was no documented evidence the preventative antibiotics were ordered or administered and the urology appointment was cancelled without documented rationale.

Inspectors wroteBased on observation and interview during the recertification survey conducted 9/25/2023-9/28/2023, the facility did not ensure residents' right to a safe, clean, comfortable, and homelike environment for 7 isolated areas (elevator #1, unit 1 hallway, and resident rooms #1, #13, #18, #19, and #29) reviewed. Specifically, elevator #1's access door was unclean with brown, sticky debris, and the walls to the entrance of the elevator on both sides had scraped paint; call bells were not within reach for multiple resident rooms (resident rooms #1, #13, #18, #19 and #29); there was a strong urine odor on unit 1 near the first floor elevator and in room [ROOM NUMBER]; and staff was observed using their personal cell phone near resident areas on unit 2 at the nursing station.

Inspectors wroteBased on record review and interview during the recertification survey conducted 9/25/2023-9/28/2023, the facility did not ensure that resident Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) System within 14 days after completion for 5 of 5 residents (Residents #4, #8, #9, #12, and #48) reviewed. Specifically, the MDS assessments for Residents #4, #8, #9, #12, and #48 were not transmitted to CMS within 14 days of completion.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 9/25/2023-9/28/2023, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Residents #35 and #267) reviewed. Specifically, registered nurse (RN) Infection Preventionist (IP) #9 was observed not following enhanced barrier precautions (EBP) when assessing Resident #35's right ankle wound and did not perform appropriate hand hygiene. Resident #267 was on EBP for an open wound and received personal hygiene care by 3 certified nurse aides (CNAs #1, #3, and #11) who did not wear the required personal protective equipment (PPE).

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00245515) surveys conducted from 6/28/21-7/1/21, the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for 3 of 3 meal trays tested. Specifically, food was not served at palatable and safe temperatures.

Inspectors wroteBased on observation and interview during the recertification survey conducted 6/28/21-7/1/21, the facility did not ensure the storage, preparation, distribution, and service of food was in accordance with professional standards for food service safety for 1 isolated area (the main kitchen). Specifically, the #10 can opener was unclean, sticky, and soiled with food debris and the exhaust hood over the stove was dust and grease laden.