Oakhill Healthcare

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) who required the use of a mechanical lift with the assistance of two staff members for transfers, the Facility failed to ensure he/she was provided with the appropriate assistive device (correct size mechanical lift sling/pad) in order to maintain his/her safety during a transfer, when Certified Nurse Aide (CNA) #1 and CNA #2 used a sling pad that was too big for him/her, Resident #1 slid out of the sling pad during the transfer, fell to the floor, and was transferred to the Hospital Emergency Department (ED) for an evaluation. Findings Include: Review of the Facility's Policy titled, Safe Lifting and Movement of Residents, dated as revised May 2018, indicated the following: [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents had a homelike environment. Specifically, the facility failed to: 1. Ensure Resident #1's fall mats and walls were in good repair and clean; and 2. Ensure residents on the B-Unit and C-Unit had an environment that was in good repair and homelike.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of practice for one Resident (#27), out of a total sample of 19 residents, when they did not implement a physician's order for referral to psychiatric services following a monthly medication regimen review.

Inspectors wroteBased on record review and interview, the facility failed to ensure that specialized rehabilitation services were provided to assist in maintaining the highest practicable level functioning for one Resident (#33), out of a total sample of 19 residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure staff maintained accurate medical records for three Residents (#2, #87, #91), out of a total sample of 19 residents. Specifically, the facility failed:1. For Resident #2, to ensure the Resident's active Physician's Orders accurately reflected the Resident's advance directives as indicated on the Resident's Massachusetts Orders for Life Sustaining Treatment (MOLST);2. For Resident #87, to ensure information regarding a potential resident-to-resident altercation and follow up assessment and intervention were documented; and3. For Resident #91, to document information of an assessment on a potential cause for hospitalization or change in condition for Resident #91 prior to their transportation to the emergency room (ER).

Inspectors wroteBased on record review and interview, the facility failed for one Resident (#7), out of a total sample of 19 residents, to notify the physician of a significant weight loss of 11 percent over 90 days, that was unplanned and unexpected.

Inspectors wroteBased on record review and interviews, the facility failed to ensure for one Resident (#2), out of a total sample of 19 residents, that the Resident was free from chemical restraints. Specifically, the facility failed to address a recommended gradual dose reduction (GDR) of his/her physician's ordered Risperidone (antipsychotic medication).

Inspectors wroteBased on interview, record review, and policy review, the facility failed for one Resident (#87), out of a total sample of 19 residents, to implement their abuse policy and procedure when there was a report of potential sexual abuse on 12/25/25.

Inspectors wroteBased on interview and review of the Healthcare Facility Reporting System (HCFRS), the facility failed for one Resident (#87), out of a total sample of 19 residents, to report an alleged violation of potential sexual abuse within 24 hours as required under the Elder Justice Act.

Inspectors wroteBased on interview and document review, the facility failed to thoroughly investigate allegations of sexual abuse for one Resident (#87), out of a total sample of 19 residents.

Inspectors wroteBased on record review and interview, the facility failed to provide indwelling catheter (a flexible tube inserted into the bladder to drain urine outside of the body) care and management consistent with professional standards for one Resident (#65), out of a total sample of 19 residents. Specifically, the facility failed to ensure the Foley catheter was positioned below the bladder draining with the flow of gravity.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications with a shortened expiration date were properly labeled once opened, in one medication cart out of three medication carts observed.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure:1. The main kitchen floor and walk-in refrigerator shelving were maintained in a sanitary and safe condition; and2. Labeling and dating of refrigerated items in two of four kitchenettes.

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to ensure proper hand hygiene after handling contaminated equipment and follow infection control standards while administering medications for two Residents (#15 and #44), out of five residents observed during medication administration.

Inspectors wroteBased on interview and document review, the facility failed to ensure residents had the right to voice and formulate grievances, have those grievances responded to promptly, and be provided a resolution to their grievance. Specifically, the facility failed to: 1. Have voiced grievances investigated and addressed, for two Residents (#86 and #68), out of a sample of 18 residents; and 2. Ensure residents had access to grievance/concern forms so they could formulate grievances anonymously, should they choose not to alert a staff member to their concern.

Inspectors wroteBased on document review and interview the facility failed to ensure Section C (Cognitive patterns) of the Minimum Data Set (MDS) assessment was complete and accurate to reflect the status of seven Residents (#86, #250, #60, #17, #9, #55, #40), out of a sample of 18 current residents and one discharged Resident (#97), who also had an incomplete pain section (Section J), out of a sample of three discharged records reviewed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure sufficient staffing to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to have sufficient staffing on the weekends as indicated on the payroll-based journal (PBJ) report submitted to Centers for Medicare and Medicaid Services (CMS) for Fiscal Year Quarter 3, 2024.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Handle ready to eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another); and 2. Properly label and date food products, and maintain safe and clean equipment in two of three nourishment kitchenettes.

Inspectors wroteBased on observation, document review, and interview, the facility failed to maintain accurate medical records in accordance with professional standards and practices for five Residents (#9, #15, #17, #55, and #10), out of 18 sampled residents. Specifically, the facility failed: 1. For Resident #9, to obtain a matching Physician's order for advanced directives in the Resident's Electronic Medical Record (EMR) which accurately reflected his/her wishes as indicated on the Resident's Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form; 2. For Resident #15, to obtain a matching Physician's order for advanced directives in the EMR which accurately reflected his/her wishes as indicated on the Resident's MOLST form; 3. [...]

Inspectors wroteBased on interview and document review, the facility failed to explain binding arbitration agreements and provide the Residents or their responsible party with the right to fully review the agreement for two of two Residents (#60 and #92) that had signed Arbitration agreements in the facility.

Inspectors wroteBased on interview and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee which included the required members at their meetings. Specifically, the facility Medical Director failed to attend the last two quarterly QAPI meetings and the laboratory and pharmacy providers had not attended any of the four quarterly QAPI meetings throughout the year 2024.

Inspectors wroteBased on document review and interview, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed: 1. For Residents #17 and #52, to ensure staff used appropriate personal protective equipment (PPE) for enhanced barrier precautions (EBP) when providing care; and 2. To have a written water management plan and documentation to ensure a facility risk assessment was conducted to identify where Legionella (bacteria that can cause Legionnaires' disease, a serious type of pneumonia) and other opportunistic waterborne pathogens could grow and spread in the facility's water system.

Inspectors wroteBased on record review and interview, for one Resident (#5), from a total sample of 18 residents, the facility failed to ensure staff documented pertinent information in the medical record including the discharge/transfer destination, reason for the discharge/transfer, a summary of the resident's current medical status and failed to ensure that necessary information was communicated to the receiving health care institution to ensure a safe and effective transition of care.

Inspectors wroteBased on document review and interview, the facility failed to ensure two Residents (#250 and #60) were offered or provided a summary of their baseline care plans, out of a total sample of 18 residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to review and revise the care plan for one Resident (#22), out of a total sample of 18 residents. Specifically, the facility failed to ensure the care plan was updated with current Health Care Proxy (HCP) status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards of practice for three Residents (#95, #33, and #22), out of a total sample of 18 residents and three closed records. Specifically, the facility failed to ensure: 1. For Resident #95, that the Registered Nurse (RN), who made a pronouncement of death, documented the assessment in the medical record as required; 2. For Resident #33, that all components of wound care recommendations were implemented timely and air mattress settings were in accordance with physician's orders; and 3. For Resident #22, that a physician's order was in place to transfer the Resident to the hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment was free from accident hazards for one Resident (#85), out of a total sample of 18 residents. Specifically, the facility failed to implement interventions on the comprehensive care plan to ensure safety precautions were taken for resident safety as related to smoking and complete an accurate initial and quarterly smoking evaluation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary respiratory care and services for one Resident (#22), out of a total sample of 18 residents. Specifically, the facility failed to ensure oxygen (O2) equipment was maintained in a sanitary manner to help decrease the risk of potential contamination and infection.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for two Residents (#39, #22) with a history of trauma, out of a total sample of 18 residents.

Inspectors wroteBased on records reviewed and interviews, for one Resident (#55), out of 18 sampled residents, the facility failed to ensure the Resident was seen by the physician at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with alternate visits by a nurse practitioner as indicated.

Inspectors wroteBased on document review and interview, the facility failed to ensure the monthly medication regimen review (MRR) for two Residents (#10 and #40), out of a total sample of 18 residents, were included in the medical record or readily available for review to indicate the Physician's response to the recommendations made by the Pharmacist and that recommendations for Resident #40 were acted upon in a timely manner.

Inspectors wroteBased on record review and interview, the facility failed to ensure one Resident's (#40) drug regimen was free from unnecessary psychotropic medications, out of a total sample of 18 residents. Specifically, the facility failed to ensure as needed antianxiety medications were limited to 14 days or extended beyond 14 days with a documented clinical rationale and duration.

Inspectors wroteBased on observation and interview, the facility failed to ensure all medications used in the facility were stored in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Provide a permanently affixed compartment and separate from all other medications for the storage of one schedule IV (low potential for misuse and dependence) and one schedule III (moderate to low potential for physical and psychological dependence) controlled substance in one of three medication room refrigerators reviewed; and 2. Ensure medications were not left unsecured when not in direct supervision of the licensed nurse.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Notice of Transfer/Discharge was issued to four Residents (#1, #85, #22 and #5), out of a sample of 18 current residents and three discharged residents. Specifically, the facility failed to notify the Resident/Resident Representative in writing for the reason of transfer and send a copy of the notice to the ombudsman when emergently transferred to the hospital.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Bed Hold Policy Notice was issued to four Residents (#1, #85, #22 and #5), out of a sample of 18 current residents and three discharged residents. Specifically, the facility failed to provide written notice of the facility's bed-hold policy to the resident/resident representative when transferred to the hospital.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had a court appointed Legal Guardian in place to make his/her health care decisions, the Facility failed to ensure his/her Guardian was promptly notified of changes in his/her medication administration and discontinuation of medications.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained a complete and accurate medical record, when nursing failed to document his/her skin assessment and a fall in his/her medical record.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure that infection control measures were implemented to promote a safe, sanitary environment and to help prevent the development and potential transmission of communicable disease and infection, regarding storage of resident medication. Specifically, 1 of 2 facility medication carts inspected was found not to be clean and sanitary.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to meet the needs of one Resident (#15), out of a total sample of 21 residents. Specifically, the facility failed to ensure Resident #15's call light was within reach.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to provide a written summary of the baseline care plan for two Residents (#273, #323), out of 21 sampled residents. Specifically, the facility failed: 1. For Resident #273, to provide a written summary of the baseline care plan and medication review to the Resident or Resident representative; and 2. For Resident #323, to ensure that staff developed and implemented a baseline care plan or a comprehensive care plan within 48 hours as required for the Resident's cerebral infarction due to embolism of left middle cerebral artery and cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for one Resident (#49), out of 21 sampled residents. Specifically, the facility failed to develop a care plan to address the Resident's diagnosis of psychosis.

Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed to ensure staff provided the necessary respiratory care and services for one Resident (#18), out of a total sample of 21 residents. Specifically, the facility failed to ensure Oxygen was administered according to physician's orders.

Inspectors wroteBased on record review, policy review, and interviews, the facility failed to develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for one Resident (#49) with a history of trauma, out of a total sample of 21 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were free of significant medication errors for one Resident (#22), out of a total sample of four residents. Specifically, the facility failed to ensure the daytime dose of Divalproex Sodium (used to treat seizure disorders, certain psychiatric conditions) was given as ordered.

Inspectors wroteBased on record review, interview, and the Beneficiary Protection Notification Review, the facility failed to issue the appropriate Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for one Resident (#50), out of three resident records reviewed.