Oak Hills Living Center

In the surveyor’s words

From the most serious findings on record at Oak Hills Living Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 12, 2024

  Based on observation, interview, and document review, the facility failed to comprehensively assess each fall and identify causal factors to determine reason for falls, identify potential effective interventions to decrease the risk for falls, failed to comprehensively evaluate and implement fall interventions for 2 of 3 residents (R1, R3) reviewed for falls. The facility's failures resulted in an immediate jeopardy for R1 who sustained a right hip fracture from the 9th fall. The IJ began on 3/28/24, when the facility failed to complete a comprehensive causal analysis, and implement appropriate interventions after R1 self-transferred to the bathroom resulting in his 9th fall from self-transfers which subsequently resulted in, hospitalization , and right hip fracture with surgical repair. […]

• Immediate jeopardy, isolatedF689Sep 13, 2023

  Based on interview, and document review the facility failed to safely use a mechanical lift per manufacture instruction to transfer 1 of 1 residents (R2) who required a mechanical lift for transfers. This resulted in R2 falling from a lift, sustaining major injuries. R2 subsequently died 10 days following the fall. In addition the facility failed to conduct a thorough investigation to determine the cause of the fall from the lift. This resulted in immediate jeopardy (IJ) for R2. The IJ began on [DATE], at approximately 9:30 a.m. when R2 fell from the lift during a transfer sustaining a major head injury and right upper arm fracture after two nursing assistants (NAs) were transferring a resident using the mechanical lift. […]

• Immediate jeopardy, isolatedF689May 18, 2023

  Based on interview, observation and document review, the facility failed to provide adequate supervision for 1 of 1 residents (R1) who despite being at risk for elopement and wearing an elopement security band, left the facility unsupervised and without staff knowledge. This resulted in immediate jeopardy when R1 walked 218 yards across uneven terrain into a parking lot of a neighboring apartment complex placing him at risk for serious harm, impairment, or death. The immediate jeopardy began on 5/4/23 at 3:25 p.m., when R1 left the facility unsupervised and was identified on 5/4/23 at 3:55 p.m., when the facility was notified by a tenant at the neighboring apartment complex and the facility arrived to pick up R1. […]

• Actual harm, isolatedF689Jun 18, 2025

  Based on interview and document review the facility failed to implement a known safety intervention of a gait belt when ambulating a resident to prevent accident hazards for 1 of 1 residents (R1) who had a fall with major injury. This resulted in harm when R1 sustained a femur fracture. The facility corrected the deficiency prior to the survey, so the citation was issued at past non-compliance. Findings include: R1's face sheet dated 5/23/25, identified diagnoses of type 2 diabetes (condition that affects how the body uses insulin and sugar), peripheral vascular disease (narrowed arteries reduce blood flow to the arms or legs), absence of right foot, edema (swelling), and open-angle glaucoma (gradual vision loss leading to blindness). […]

• No harm, potential for more than minimal, widespreadF880Dec 13, 2023

  Based on interview and document review, the facility failed to have a water management program consistent with nationally accepted standards, e.g., ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) or CDC (Centers for Disease Control and Prevention). This had the potential to effect all 83 residents who resided in the facility. Findings included: During an interview on 12/13/23 at 9:53 a.m., maintenance worker (MW)-A stated he was responsible for the facility water management program. MW-A explained the actions he took related to the water management program which included testing water for chlorine levels, measuring water temperatures at various sites in the facility, and running water in vacant resident rooms. […]