Oakhill Healthcare

In the surveyor’s words

From the most serious findings on record at Oakhill Healthcare, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF584Jan 6, 2026

  Based 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.Findings include: 1. Resident #1 was admitted to the facility in August of 2018 with diagnoses including cerebrovascular accident (stroke).Review of the Minimum Data Set assessment, dated 10/16/25, indicated on the staff assessment for mental status the Resident has a short-term and long-term memory impairment.On 12/30/25 at 7:59 A.M., the surveyor observed the following in Resident #1's room:- Resident #1 in bed with a ripped fall mat with approximately a 6-inch by… […]

• No harm, potential for more than minimal, patternF658Jan 6, 2026

  Based 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. Findings include: Review of the facility's policy titled Medication Regimen Review, dated 8/2020, indicated but was not limited to the following:- resident specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the resident's active medical record and reported to the Director of Nurses (DON), Medical Director, and or prescriber, as appropriate- recommendations are acted upon and documented by the facility staff and/or the… […]

• No harm, potential for more than minimal, patternF825Jan 6, 2026

  Based 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. Findings include: Review of the Rehabilitation Consultant Company policy titled Policy: 8.1 - Evaluations, revised 7/21/25, indicated but was not limited to the following:POLICY:-all patients identified as needing an assessment of functional status or assessment of indicators impacting quality of life and having potential to benefit from rehabilitation, habilitative, and/or skilled functional maintenance therapy be evaluated to determine an appropriate plan of care;-an evaluation is an assessment of the patient's physical and functional… […]

• No harm, potential for more than minimal, patternF842Jan 6, 2026

  Based 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). […]

• No harm, potential for more than minimal, patternF585Nov 6, 2024

  Based 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. […]