Oak Hill Rehabilitation & Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 26, 2022

  Based on review of policies, clinical records, and facility reports, as well as staff interviews, it was determined that the facility failed to ensure residents' environment remained free of accident hazards, and failed to ensure adequate interventions and supervision to prevent elopements which threatened the resident's safety and increased the resident's risk for accidents and bodily injury or harm for four of four residents identified at risk for elopement. The facility further relied on it's alarm system to prevent unsupervised exits, which placed residents in immediate jeopardy of the likelihood of serious bodily injury, harm or death. […]

• Actual harm, isolatedF689Aug 12, 2026

  Based on review of facility policies, clinical records, and facility investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that the residents' environment remained as free from accident hazards as possible for one of six residents reviewed (Resident 1) who used a shower chair that was not locked, resulting in a fall with a right hip fracture.Findings include: The facility's Shower/Tub policy, dated February 18, 2026, revealed that the steps in the procedure for a shower include; once the resident is taken into the shower room and placed under the shower, the shower chair is to be firmly positioned and locked. […]

• No harm, potential for more than minimal, widespreadF812Jun 13, 2024

  Based on review of policies, observations, and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions, in accordance with professional standards for food service safety. Findings include: The facility's policy regarding sanitization, dated June 7, 2024, indicated that the food service area is maintained in a clean sanitary manner. All kitchen areas are kept clean and free from debris. All utensils, counters, shelves and equipment are kept clean and maintained. Observations in the main kitchen on June 13, 2024, at 9:23 a.m. […]

• No harm, potential for more than minimal, patternF812Aug 12, 2026

  Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food under sanitary conditions. Findings include: The facility's policy for dishwasher use, dated February 18, 2026, revealed that staff were to monitor the final rinse temperature during operation and were to record the temperature on the dishwasher temperature log.Observations on August 12, 2026, at 9:15 a.m. revealed that staff were running the dishwasher. Observations of the dishwasher temperature log, dated August 2026, revealed that the dishwasher wash temperatures and rinse temperatures were to be recorded every a.m. and p.m. […]

• No harm, potential for more than minimal, patternF761Jul 8, 2026

  Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to ensure that medications were properly stored and labeled in a medication cart. Findings include: The facility's policy for medication labeling and storage dated February 18, 2026, indicated that medications are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary method. […]