Oak Hill Center for Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Oak Hill Center for Rehabilitation and Nursing, in the surveyor’s own words.

• Actual harm, isolatedF684Sep 11, 2025

  Based 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). Findings include:Review of Resident 1's clinical record revealed diagnoses that included Alzheimer's Disease and Dementia (a progressive cognitive and mental decline that is severe enough to interfere with daily life, affecting memory, thinking, language, and judgment). […]

• Actual harm, isolatedF600Jun 4, 2025

  Based 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). Findings include: Review of the current facility policy, titled Pre-Thickened Liquids Policy, read in part, Pre-thickened liquids will be provided at bedside in individual packaged containers per physician orders. […]

• Actual harm, isolatedF805Jun 4, 2025

  Based 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). Findings include: Review of facility policy, titled Pre-Thickened Liquids Policy, read in part, Pre-thickened liquids will be provided at bedside in individual packaged containers per physician orders. […]

• Actual harm, isolatedF684Oct 30, 2024

  Based 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). Findings include: Review of the facility policy, titled Collecting a Urine Specimen from a Closed Drainage System, read, in part, The purpose of this procedure is to obtain an uncontaminated urine specimen from a resident with a catheter. The policy included steps in the specimen collection procedure to prevent specimen contamination. […]

• Actual harm, isolatedF600Apr 8, 2024

  Based 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). Findings include: Review of facility policy, titled Abuse Prevention Program, dated January 1, 2022, revealed Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation .'Neglect' is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness Signs of Actual Physical Neglect: 6. […]