Oak Hill Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Oak Hill Health & Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF645Jul 2, 2025

  Based 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.Findings include:1) Review of Resident #44 Preadmission Screening and Resident Review (PASRR) dated 7/27/2024 did not document serious mental illness or intellectual disability.Review of Resident #44's admission record resident was readmitted on [DATE] with diagnosis including but not limited to anxiety disorder, major depressive disorder and psychosis. […]

• No harm, potential for more than minimal, patternF693Nov 2, 2022

  Based 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. Findings include: 1. During an observation on 11/1/2022 at 8:15 AM, Resident #183 was frail, eyes closed with a pale complexion and tube fed with [MEDICATION(S)] 1.5. The formula was hung in a clear Enteral Feeding Bag and pump was running at 60 milliliters (ml) per hour (ml/hr). The bag contained approximately 800 ml of formula. The formula appeared thick and lumpy, with cottage cheese like appearance and consistency. […]

• No harm, potential for more than minimal, patternF758Nov 2, 2022

  Based on observation, interview, and record review, the facility failed to ensure residents who use [CONDITION(S)] drugs received behavioral interventions for 3 of 3 reviewed residents, Residents #5, #56, and #70, in a total sample of 39 residents. Findings include: 1. Review of Resident #70's medical records revealed the resident was admitted on [DATE] with the diagnoses including [CONDITION(S)], dementia with other behavioral disturbance, paranoid personality disorder, and personal history of [CONDITION(S)]. Review of Resident #70's Medication Administration Record (MAR) revealed the resident was receiving [MEDICATION(S)] 0.25 mg [milligrams] for anxiety, [MEDICATION(S)] for depression, and [MEDICATION(S)] 1 mg at bedtime, and 0.5 mg daily for agitation. […]

• No harm, potential for more than minimal, patternF812Nov 2, 2022

  Based 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. Findings include: During an initial tour of the facility's walk-in freezer conducted with the Kitchen Manager on 10/30/2022 beginning at 9:48 AM, the surveyor observed unlabeled and undated partial bags of breaded chicken tenders, French fries and mixed vegetables, opened and partially unwrapped box of corn on the cob, freezer storage bags with onion rings and sliced potatoes, an unwrapped single chicken breast portion on top of a box of individually wrapped frozen fish portions, an open plastic food storage bag with French fries, and an opened and partially unwrapped box of French toast slices in the walk-in… […]

• No harm, potential for more than minimal, patternF888May 23, 2022

  Based on interview and record review, the facility failed to ensure all staff were fully vaccinated and failed to identify an appropriate clinical reason for the contraindication of the COVID-19 vaccine for seven of nine sampled staff. The COVID-19 staff vaccination rate was 95% which had an isolated impact on residents. Findings include: On 5/12/22 at 4:25 PM, review of the facility's updated COVID-19 staff vaccination information identified there were a total of 145 staff: 131 were fully vaccinated, six staff had a granted non-medical exemption, one staff had a granted medical exemption, and one staff was newly hired. However, the staff who was granted a medical exemption did not have a qualifying clinical reason. […]