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Inspection visit

Health inspection

OAK HILL REHABILITATION & HEALTHCARE CENTERCMS #39564621 citations on this visit
21 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 21 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to document the opportunity to formulate advance directives and failed to document the resident's decision to accept or decline assistance to formulate advance directives for four of 28 residents reviewed (Residents 6, 26, 34, 41). Findings include: The facility's policy regarding advance directives (instructions regarding the provision of health care and life sustaining measures when the resident is incapacitated), dated June 7, 2024, indicated that upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. If the resident indicated that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline the assistance, and nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated May 30, 2024, revealed that the resident was cognitively intact, usually understood and understands others, required extensive assistance with care needs, and had diagnoses that include chronic obstructive pulmonary disease (a lung disease that causes breathing problems and airflow restriction). A social history form for Resident 6, dated July 31, 2024, indicated that the resident did not have advance directives and that advance directives were discussed with the resident. However, there was no documented evidence that information was provided to the resident on advance directives and that assistance was offered to formulate advance directives. There was no documented evidence as to the resident's decision to accept or decline assistance to formulate advance directives. A quarterly MDS assessment for Resident 26, dated May 10, 2024, revealed that the resident was cognitively intact, usually understood and understands others, required assistance with care needs, and had diagnoses that include cerebral infarction (a condition that occurs when the brain is damaged due to lack of oxygen and nutrients). A social history form for Resident 26, dated August 17, 2023, indicated that the resident did not have advance directives and that advance directives were discussed with the resident's family. Page 1 of 24 395646 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few However, there was no documented evidence that information was provided to the resident's family on advance directives and that assistance was offered to formulate advance directives. There was no documented evidence as to the resident's family's decision to accept or decline assistance to formulate advance directives. An admission MDS assessment for Resident 34, dated May 13, 2024, revealed that the resident was cognitively intact, usually understood and understands others, required assistance with care needs, and had diagnoses that included hemiplegia (paralysis or weakness to one side of the body due to brain injury), expressive language disorder (affects how thoughts and ideas are communicated), and a history of traumatic brain injury (TBI) (serious medical condition caused by a blow or jolt to the head). A social history form for Resident 34, dated May 13, 2024, indicated that the resident did not have advance directives and that advance directives were discussed with the resident. However, there was no documented evidence that information was provided to the resident on advance directives and that assistance was offered to formulate advance directives. There was no documented evidence as to the resident's decision to accept or decline assistance to formulate advance directives. Interview with the Social Service Coordinator on June 12, 2024, at 1:43 p.m. revealed that she did discuss advance directives with Resident 34 on admission but did not document in the medical record that information was provided on advance directives, that assistance was offered to formulate advance directives, or the the resident's decision to formulate or not to formulate an advance directive. An admission MDS assessment for Resident 41, dated June 10, 2024, revealed that the resident was cognitively intact, usually understood and understands others, required assistance with care needs, and had diagnoses that include acute respiratory failure (a life-threatening condition that occurs when the lungs cannot provide enough oxygen to the blood). A social history form for Resident 41, dated June 7, 2024, indicated that the resident did not have advance directives and that advance directives were discussed with the resident. However, there was no documented evidence that information was provided to the resident on advance directives and that assistance was offered to formulate advance directives. There was no documented evidence as to the resident's decision to accept or decline assistance to formulate advance directives. Interview with the Social Service Coordinator on June 12, 2024, at 1:43 p.m. revealed that she did discuss advance directives with Resident 41 on admission but did not document in the medical record that information was provided on advance directives, that assistance was offered to formulate advance directives, or the resident's decision to formulate or not to formulate an advance directive. Interview with the Nursing Home Administrator on June 13, 2024, at 11:57 a.m. revealed that she felt the facility's process for addressing advance directives met the regulatory requirements and that the social history forms for Residents 6, 26, 34 and 41 addressed advance directives. 28 Pa. Code 201.29(a)(d) Resident Rights. 395646 Page 2 of 24 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that notices of Medicare non-coverage were issued timely for two of three discharged residents reviewed (Residents 44, 45). Residents Affected - Few Findings included: The facility's policy regarding notices of Medicare non-coverage, dated June 7, 2024, indicated that Skilled Nursing Facility Beneficiary Notices will be issued following the Medicare Claims Processing Manual Chapter 30 Section 260 with the purpose to inform beneficiaries on the Medicare covered services ending and how to request an appeal. A nursing note for Resident 44, dated May 1, 2024, at 11:20 a.m. revealed that she was discharged home. There was no documented evidence that Resident 44 was issued a notice of Medicare non-coverage prior to the end her of Medicare coverage. A nursing note for Resident 45, dated February 28, 2024, at 7:16 p.m. revealed that she was discharged . There was no documented evidence that Resident 45 was issued a notice of Medicare non-coverage prior to the end her of Medicare coverage. Interview with the Nursing Home Administrator on June 11, 2024, at 11:24 a.m. confirmed that there was no documented evidence that the notice of Medicare non-coverage was issued to Resident 44 and Resident 45 prior to the end their of Medicare coverage and it should have been. 28 Pa. Code 201.18(e)(1) Management. 395646 Page 3 of 24 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment for four of 28 residents reviewed (Residents 4, 8, 9, 29). Residents Affected - Some Findings include: Observations of Resident 4's wheelchair on June 10, at 11:42 a.m.; June 11, 2024, at 12:18 p.m.; and June 12, 2024, at 9:00 a.m. revealed that the resident was resting his hand/arm on an oversized right armrest that had a moderate accumulation of removable, dried-on debris. Observations of Resident 8's wheelchair on June 10, 2024, at 11:47 a.m.; June 11, 2024, at 2:16 p.m.; and June 12, 2024, at 11:12 a.m. revealed that the resident's cushioned wheelchair had a moderate to large amount of thick, removable dust/debris on the metal supports under the seat and an accumulation of dirt and sticky debris that caused the seat cushion to stick to the wheelchair seat. Observations of Resident 9's wheelchair on June 10, 2024, at 11:38 a.m.; June 11, 2024, at 1:20 p.m.; and June 12, 2024, at 1:32 p.m. revealed that there was a large amount of removable dust/debris on the wheels and the metal supports under the chair. Observations of Resident 29's wheelchair on June 10, 2024, at 11:55 a.m. and June 11, 2024, at 2:30 p.m. revealed that the front wheels of the wheelchair had an accumulation of removable, white, dried-on debris. Interview with the Housekeeping Supervisor on June 13, 2024, at 12:50 p.m. confirmed that Resident's 4, 8, 9 and 29's wheelchairs should have been clean. He revealed that it was his impression that the nurse aides cleaned the residents' wheelchairs. Interview with the Nursing Home Administrator on June 13, 2024, at 1:31 p.m. confirmed that the removable dust, dirt and debris on Resident 4's, 8's, 9's and 29's wheelchairs should not have been there, and they should have been cleaned. 28 Pa. Code 201.29(j) Resident Rights. 28 Pa. Code 207.2(a) Administrator's Responsibility. 395646 Page 4 of 24 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that the status of nursing licenses was checked with the State Board of Nursing for one of two nurses reviewed (Registered Nurse 4) and failed to complete a Nurse Aide Registry verification for one of three nurse aides reviewed (Nurse Aide 5). Residents Affected - Few Findings include: The facility's policy regarding abuse prevention program, dated June 7, 2024, indicated that the facility would conduct employee background checks and would not knowingly employ or otherwise engage any individuals who have had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or have a disciplinary action in effect against his or her professional license by a state licensure body as a result finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. The personnel file for Registered Nurse 4 revealed a start date of March 12, 2024. However, there was no documented evidence until June 13, 2024, that her license was verified with the state board. The personnel file for Nurse Aide 5 revealed a start date of March 4, 2024. However, there was no documented evidence that the nurse aide's standing on the Pennsylvania Nurse Aide Registry was verified until March 21, 2024. Interview with the Human Resources Director on June 13, 2024, at 10:54 a.m. confirmed that Registered Nurse 4's start date was March 12, 2024, and her license was not verified with the State Board of Nursing, but used a quick confirm website. She also confirmed that Nurse Aide 5 had a start date of March 4, 2024, and there was no documented evidence that a registry verification was completed prior to her start date. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 395646 Page 5 of 24 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident, the resident's representative, and the state long-term care ombudsman in writing regarding the reason for transfer to the hospital for two of 28 residents reviewed (Residents 6, 26). Findings include: The facility's policy regarding transfer or discharge, dated June 7, 2024, indicated that the facility would provide written notification to inform residents, residents' representatives, and the state long-term care ombudsman of hospitalization. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated May 30, 2024, indicated that the resident was cognitively intact, required extensive assistance from staff for daily care needs, and had a diagnosis of chronic congestive heart failure. Nursing notes for Resident 6, dated February 21, 2024, indicated that the resident was transferred to the hospital on that date. There was no documented evidence that written notification of transfer was provided to the resident, the resident's representative, or the state long-term care ombudsman. A quarterly Minimum Data Set (MDS) assessment for Resident 26, dated May 10, 2024, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had a diagnosis of chronic congestive heart failure. Nursing notes for Resident 26, dated March 8, 2024, indicated that the resident was transferred to the hospital on that date. There was no documented evidence that written notification of transfer was provided to the resident, the resident's representative, or the state long-term care ombudsman. Interview with the Nursing Home Administrator on June 13, 2024, at 12:25 p.m. confirmed that a written notification of hospital transfer was not provided to Resident 6 or Resident 26, their representatives, or the state long-term care ombudsman as required. 28 Pa. Code 201.29(j) Resident Rights. 395646 Page 6 of 24 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a bed-hold notice was provided to the resident's responsible party for two of 28 residents reviewed (Residents 6, 26) who were transferred to the hospital. Findings include: The facility's policy regarding bed-hold notices, dated June 7, 2024, indicated that the facility would provide notification to inform residents and/or the resident's representative of their rights regarding holding the resident's current bed in the facility when a resident must be hospitalized or temporarily leaves the facility for medical or therapeutic reasons. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated May 30, 2024, indicated that the resident was cognitively intact, required extensive assistance from staff for daily care needs, and had a diagnosis of chronic congestive heart failure. Nursing notes for Resident 6, dated February 21, 2024, indicated that the resident was transferred to the hospital on that date. There was no documented evidence that a bed-hold notice was provided to the resident's responsible party as required. A quarterly Minimum Data Set (MDS) assessment for Resident 26, dated May 10, 2024, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had a diagnosis of chronic congestive heart failure. Nursing notes for Resident 26, dated March 8, 2024, indicated that the resident was transferred to the hospital on that date. There was no documented evidence that a bed-hold notice was provided to the resident's responsible party as required. Interview with the Nursing Home Administrator on June 13, 2024, at 12:25 p.m. confirmed that a bed-hold notice was not provided to Resident 6's or Resident 26's responsible party as required. 28 Pa. Code 201.29(j) Resident Rights. 395646 Page 7 of 24 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a baseline care plan was developed that included resident-specific information necessary to properly care for one of 28 residents reviewed (Resident 242). Findings include: The facility's policy for baseline care plans (includes the minimum healthcare information necessary to properly care for a resident), dated June 7, 2024, indicated that a baseline care plan would be developed within 48 hours of the resident's admission. The baseline care plan would be used until the staff conducts the comprehensive assessment and develops an interdisciplinary person-centered care plan. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 242, dated June 7, 2024, revealed that the resident was admitted on [DATE], was understood, was able to understand others, required assistance with care needs, was taking an anticoagulant (a medication used to thin the blood to prevent blood from clotting), and had diagnoses that included atrial fibrillation (irregular heart rhythm), transient ischemic attack (TIA) (a brief blockage of blood flow to the brain that causes stroke-like symptoms) and a history of thrombosis (vascular disease caused by formation of a blood clot inside a blood vessel) and embolism (blockage of an artery caused by a blood clot). A physician's order for Resident 242, dated June 3, 2024, included an order for the resident to receive 15 milligrams (mg) of rivaroxaban (an anticoagulant) daily. There was no documented evidence that a baseline care plan was developed to address Resident 242's need for an anticoagulant. Interview with the Nursing Home Administrator on June 13, 2024, at 9:31 a.m. confirmed that there was no documented evidence that a baseline care plan was developed to address Resident 242's need for an anticoagulant. 28 Pa. Code 201.24(e)(4) admission Policy. 395646 Page 8 of 24 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 28 residents reviewed (Resident 41). Residents Affected - Few Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 41, dated June 10, 2024, revealed that the resident was understood, understands, and required assistance from staff for daily care needs. Physician's orders for Resident 41, dated June 5, 2024, included an order to cleanse the right shin with normal saline, pat dry with ABD (a gauze pad used to treat large wounds), and wrap with rolled gauze. Observations on June 10, 2024, at 11:15 a.m. and June 11, 2024, at 1:15 p.m. revealed that Resident 41 did not have a wrap on her right leg. Resident 41 stated that she did not think the wraps had been discontinued. Review of Resident 41's Treatment Administration Record (TAR) for June 2024 revealed that the order for the leg wrap was still an active order and that the wrap was signed off as being completed on June 10 and 11, 2024. Interview with the Nursing Home Administrator on June 12, 2024, at 2:35 p.m. confirmed that the treatment for Resident 41's right shin was signed off as being completed and it was not completed as ordered by the physician. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 395646 Page 9 of 24 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that pressure-relieving interventions were in place as care planned for one of 28 residents reviewed (Resident 4) who was at risk for pressure ulcers. Residents Affected - Few Findings include: The facility's policy regarding mobility and skin integrity, dated June 7, 2024, indicated that any protective device should be provided as established by the physician. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated May 9, 2024, indicated that the resident was severely cognitively impaired, dependent on staff for care, had limited range of motion of the upper and lower extremities on both sides, and had diagnoses that included cerebral palsy (a disorder of muscle tone and exaggerated reflexes) with right hand and leg contractures. Physician's orders, dated April 30, 2024, included an order for the resident to have a right palm guard splint (a type of cushioned barrier between the fingers and the palm to prevent injury to the palm from finger contractures) on except during hygiene, and a heel pro (a type of heel off-loading device to aid in the prevention of skin breakdown) while in bed. Resident 4's care plan, revised on April 29, 2024, included that he had decreased mobility and functional abilities related to cerebral palsy, with contractures as well as intellectual and cognitive disabilities. Interventions included a right hand palm guard and a heel pro, both to prevent injury to the skin. Observations on June 12, 2024, at 9:52 a.m. revealed that Resident 4 was sitting in his high-back manual wheelchair with his right hand/arm resting on the right arm rest, and he did not have his right palm guard splint in place. Observations on June 13, 2024, at 8:00 a.m. revealed that the resident was in bed with his right arm on a pillow, the right palm guard splint was not on and the heel pro was on the chair and not elevating his heels off the mattress. Interview with Nurse Aide 1 on June 13, 2024, at 8:07 a.m. confirmed that Resident 4 was in bed with his right arm on a pillow but he was not wearing his right palm guard splint, and the heel pro was not under his feet per physician order. Interviews with the Director of Therapy and Nursing Home Administrator on June 13, 2024, at 1:00 p.m. confirmed that Resident 4 was not wearing a right palm guard splint to his right hand, and there was no heel pro under his heels per physician orders, and there should have been. 28 Pa. Code 211.12(d)(5) Nursing Services. 395646 Page 10 of 24 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to complete safety assessments for one of 28 residents reviewed (Resident 11) and failed to provide safe transport in a wheelchair for one of 28 residents reviewed (Resident 26). Findings include: The facility's policy for bed safety, dated June 7, 2024, indicated that the resident's sleeping environment shall be assessed by the interdisciplinary team considering the resident's safety, medical conditions, comfort and freedom of movement to try to prevent deaths or injuries from the beds and related equipment (including mattress). A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated May 23, 2024, revealed that the resident was cognitively impaired, required assistance from staff for his daily care needs, and had a Stage 4 pressure ulcer (pressure wound with full thickness tissue loss with exposed bone, tendon or muscle). Physician's orders for Resident 11, dated February 12, 2024, included an order for the resident to have an air mattress (an inflated mattress for pressure relief) to his bed and to check functioning every shift. Observations on June 10, 2024, at 11:52 a.m. revealed that Resident 11 was lying in bed and the bed was equipped with an air mattress. There was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to being placed on the resident's bed. Interview with the Director of Nursing on June 12, 2024, at 10:00 a.m. confirmed there was no assessment for potential safety hazards prior to the air mattress being placed on the Resident 11's bed and there should have been. A quarterly MDS assessment for Resident 26, dated May 10, 2024, revealed that the resident was cognitively intact and needed moderate assistance for all of his care. The resident's care plan, revised on March 18, 2024, revealed that the resident was at risk for falls and had muscle weakness and impaired mobility. There was no documented evidence that an assessment was completed to determine if the resident was safe to be transported in a wheelchair that was not equipped with leg rests. Observations on June 13, 2024, at 1:33 p.m. revealed that Resident 26 was being pushed through the hallway in a wheelchair by Nurse Aide 1. The resident had socks on his feet and the resident's feet were less than one inch above the floor. Upon interview with Nurse Aide 1 at that time, she indicated that the resident prefers not to have the footrests on his wheelchair. An interview with Resident 26 on June 13, 2024, at 1:44 p.m. revealed that the footrests were sitting on a chair beside him and that he preferred not to have them in place on his wheelchair. An interview with the Nursing Home Administrator on June 13, 2024, at 2:10 p.m. confirmed that while being pushed by staff in his wheelchair, Resident 26 should have his feet on the leg rests or have a care plan in place regarding his desire not to use foot rests. In addition, safety education was 395646 Page 11 of 24 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0689 Level of Harm - Minimal harm or potential for actual harm not provided regarding the dangers associated with not using footrests during transportation, and it should have. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. Residents Affected - Few 395646 Page 12 of 24 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received oxygen as ordered by the physician for one of 28 residents reviewed (Resident 2). Residents Affected - Few Findings include: The facility's policy regarding oxygen therapy, dated June 7, 2024, indicated that oxygen was to be administered in accordance with physician's orders. A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 6, 2024, revealed that the resident was cognitively intact and had diagnoses that included atrial fibrillation (an irregular heart rate causing poor blood flow) and heart failure (a condition in which the heart does not pump blood as well as it should). Resident 2's care plan, dated May 20, 2024, indicated that she had difficulty breathing related to cardiac disease. Physician's orders for Resident 2, dated August 29, 2023, included an order for the resident to receive continuous oxygen at a flow rate of 3 liters per minute via nasal cannula (tubes that deliver oxygen into the nostrils). Observations of Resident 2 on June 11, 2024, at 9:10 a.m. and 11:50 a.m. revealed that the resident was in her room receiving oxygen from an oxygen concentrator (electrical machine that concentrates oxygen from the air) that was set at 1.5 liters per minute. Interview with Registered Nurse 3 on June 11, 2024, at 12:15 p.m. confirmed that Resident 2's oxygen flow rate was set at 1.5 liters per minute and not 3.0 liters per minute as ordered by the physician. Interview with the Director of Nursing on June 11, 2024, at 12:26 p.m. confirmed that Resident 2's oxygen flow rate should be set at 3 liters per minute continuously as per physician order, and it was not. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 395646 Page 13 of 24 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for one of 28 residents reviewed (Resident 2). Residents Affected - Few Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May, 2024, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included schizophrenia and post-traumatic stress disorder (PTSD). A review of Resident 2's care plan, revised on May 20, 2024, indicated that the resident had PTSD and anxiety. There was no documented evidence the facility identified Resident 2's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring. Interview with the Nursing Home Administrator on June 13, 2024, at 12:37 p.m. revealed that the facility was not completing trauma-informed care assessments and they should be. In addition, the facility did not assess or identify specific triggers that may re-traumatize residents with past traumas to prevent triggers from occurring for Resident 2. 28 Pa. Code 201.24(e)(4) admission Policy. 28 Pa. Code 211.12(a)(d)(3)(5) Nursing Services. 28 Pa. Code 211.16(a) Social Services. 395646 Page 14 of 24 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on hire dates for three of five nurse aides reviewed (Nurse Aides 6, 7, 8). Residents Affected - Some Findings include: The facility's policy regarding performance evaluations, dated June 7, 2024, indicated that job performances of each employee shall be reviewed and evaluated at least annually. A list of nurse aides provided by the facility revealed that Nurse Aide 6 was hired on March 28, 2023, and that she was due for her annual performance evaluation in March 2024. Nurse Aide 7 was hired February 26, 2023, and was due for her annual performance evaluation in February 2024. Nurse Aide 8 was hired April 16, 2023, and was due for her annual performance evaluation in April 2024. There was no documented evidence that the annual performance evaluations were completed as required for Nurse Aides 6, 7, and 8. Interview with the Nursing Home Administrator on June 12, 2024, at 2:40 p.m. confirmed that she could not provide evidence that annual performance evaluations were completed as required for Nurse Aides 6, 7, and 8. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.20(a)(c) Staff Development. 395646 Page 15 of 24 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on a review of facility policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for three of 28 residents reviewed (Residents 2, 11, 20). Findings include: A facility policy regarding administration of pain medication, dated June 7, 2024, indicated that facility staff were to administer pain medication as ordered and to document in the resident's medical record the results of the pain assessment, medication, dose, route of administration, and the result of the medication. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 6, 2024, revealed that the resident was understood and could understand others and was receiving palliative care. Physician's orders for Resident 2, dated January 17, 2024, included an order for the resident to receive 30 milligrams (mg) of MS Contin (Morphine Sulfate - a controlled narcotic) by mouth three times a day related to palliative care. Review of the June 2024 controlled drug record (a log for tracking the inventory of controlled drugs) for Resident 2 revealed that staff signed out a dose of MS Contin for administration to the resident on June 6, 2024, at 5:00 a.m. However, a review of the Medication Administration Record (MAR) and nursing notes for Resident 2 for June 2024 revealed no documented evidence that the signed out dose of MS Contin was administered to the resident. Interview with the Nursing Home Administrator on June 12, 2024, at 2:36 p.m. confirmed that the dose of MS Contin for Resident 2 should have been documented as administered on the MAR if it was signed out on the controlled drug record. A significant change MDS assessment for Resident 11, dated May 23, 2024, revealed that the resident was cognitively impaired, required assistance from staff for his daily care needs, was receiving hospice services, and received opioid (controlled drug used to treat pain) medication. Physician's orders for Resident 11, dated February 27, 2024, included an order for the resident to receive 5 milligrams (mg) of oxycodone every six hours as needed for pain. Review of the controlled drug record for Resident 11 revealed that staff signed out a dose of oxycodone for administration to the resident on March 10, 2024, at 8:20 a.m.; March 12, 2024, at 10:30 p.m.; April 3, 2024, at 9:25 p.m.; and April 21, 2024, at 9:00 a.m. However, a review of Resident 11's nursing notes and MARs for March 2024 and April 2024 revealed no documented evidence that the signed-out doses of oxycodone were administered to the resident on those dates and times. A quarterly MDS assessment for Resident 20, dated May 7, 2024, revealed that the resident was cognitively intact, required assistance from staff for his daily care needs, had almost constant pain, and received opioid medication. A care plan for Resident 20 regarding chronic pain, dated February 7, 2024, included an intervention to administer pain medication per physician orders. 395646 Page 16 of 24 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Physician's orders for Resident 20, dated February 7, 2024, included an order for the resident to receive 5 mg of oxycodone every four hours as needed for pain. Review of the controlled drug records for Resident 20 from February through May 2024 revealed that staff signed out a dose of oxycodone for administration to the resident on February 11, 2024, at 12:00 p.m.; February 16, 2024, at 11:30 a.m.; February 18, 2024, at 1:00 p.m.; February 20, 2024, at 4:00 a.m.; February 21, 2024, at 10:00 p.m.; February 29, 2024, at 9:00 a.m.; March 5, 2024, at 11:30 a.m.; March 16, 2024, at 9:30 p.m.; April 10, 2024, at 10:00 p.m.; and May 12, 2024, at 7:20 p.m. However, a review of Resident 20's nursing notes and MARs for February 2024 through May 2024 revealed no documented evidence that the signed-out doses of oxycodone were administered to the resident on those dates and times. Interview with the Nursing Home Administrator on June 13, 2024, at 12:24 p.m. confirmed that there was no documented evidence in Resident 11's or 20's clinical records to indicate that the signed-out doses of oxycodone were administered to the residents on the above-mentioned dates and times. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 395646 Page 17 of 24 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on a review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to label multi-dose containers of medications with the date they were opened in one of one medication carts observed (Colonial Wing). Findings include: The facility's policy regarding medication labeling and storage, dated June 7, 2024, revealed that multi-dose medications that have been opened or accessed are to be dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open medication. Observations of the Colonial Wing medication cart on June 10, 2024, at 12:24 p.m. revealed one opened and undated vial of Levemir insulin, one opened and undated vial of glargine insulin, and one opened and undated bottle of .005 percent Latanoprost solution eye drops. Interview with Registered Nurse 3 on June 10, 2024, at 12:30 p.m. confirmed that the insulin vials and bottle of eye drops should have been dated with the date they were opened. Interview with the Nursing Home Administrator on June 10, 2024, at 2:58 p.m. confirmed that multidose vials of insulin and eye drops were to be labeled with the dates they were opened and discarded in accordance with the manufacturer's instructions. 28 Pa. Code 211.9(h) Pharmacy Services. 395646 Page 18 of 24 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observations and staff interviews, it was determined that the facility failed to employ a full-time qualified dietitian. Residents Affected - Few Findings include: Interview with the facility's Dietary Manager on June 10, 2024, at 9:14 a.m. revealed that the facility did not have a qualified dietician on staff as of May 20, 2024, when the previous dietician's employment ended. Interview with the Nursing Home Administrator on June 13, 2024, at 10:45 a.m. confirmed that the facility did not have a dietician or a dietician consultant employed as of June 13, 2024. 28 Pa Code 201.18(e)(1)(6) Management. 28 Pa. Code 211.6(c)(d) Dietary Services. 395646 Page 19 of 24 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 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. revealed that there was a black, removable substance on the wall near the dishwasher; kitchen shelves, where clean pots and serving pans were kept, had dust and debris on them; and the dish warmer tray had a thick, removable substance on it. Interview with the Dietary Manager on June 13, 2024, at 9:23 a.m. confirmed that the kitchen, the shelving, and kitchen equipment should be clean and free of debris and was not. 28 Pa. Code 211.6(f) Dietary Services. 395646 Page 20 of 24 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of 28 residents reviewed (Resident 2). Residents Affected - Few Findings include: The facility policy, dated June 7, 2024, indicated that documentation would be complete and accurate. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 6, 2024, revealed that the resident was cognitively intact, required the extensive assistance of two staff for daily care tasks, and had diagnoses that included heart failure and diabetes. Physician's orders for Resident 2, dated November 7, 2023, included an order to clean the reddened area on the right lower back with wound cleanser, pat dry, and apply a hydrocolloid (breathable) dressing every third day and every shift as needed. Observations on June 13, 2024, at 2:10 p.m. of Resident 2's right lower back revealed that there was no reddened area or dressing noted. Review of the June 2024 Treatment Administration Records (TAR) for Resident 2 revealed that on June 1, 4, 7 and 10, 2024, wound care was signed as being completed on the right lower back reddened area. Interview with Registered Nurse 3 and Registered Nurse 13 on June 10, 2024, at 10:36 a.m. and June 13, 2024, at 2:07 p.m., respectively, confirmed that Resident 2 did not currently have a reddened area on her right lower back that required wound care. Interview with Registered Nurse 13 on June 13, 2024, at 2:10 confirmed that if there was no wound to care for, there should be no documentation to indicate that it was done. Interview with the Nursing Home Administrator on June 13, 2024, at 2:07 p.m. confirmed that Resident 2 did not currently have a reddened area on her right lower back that required wound care; therefore, staff should not be documenting that wound care was done. 28 Pa. Code 211.5(f) Clinical Records. 395646 Page 21 of 24 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to obtain the required information from the contracted hospice provider for one of one hospice residents reviewed (Resident 11). Findings include: The facility's policy regarding the hospice program, dated June 7, 2024, indicated that facility was responsible for obtaining the hospice election of benefits form (a form signed to indicate that the individual waives all rights to traditional Medicare Part A payments for treatment related to the terminal illness) and the certification of terminal illness form (to certify a person's terminal diagnosis and life expectancy of six months or less) from the hospice provider (provider of end-of-life services) A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated May 23, 2024, revealed that the resident was cognitively impaired, required assistance from staff for his daily care needs, and was receiving hospice services. Physician's orders for Resident 11, dated May 24,2024, revealed that the resident was to receive hospice services, effective May 23, 2024, from the facility's contracted hospice provider. As of June 12, 2024, there was no documented evidence in the resident's clinical record, or in the hospice provider's clinical record, that the facility obtained the hospice election of benefits and the certification of terminal illness from the hospice provider. Interview with the Nursing Home Administrator on June 12, 2024, at 3:43 p.m. confirmed that there was no documented evidence in Resident 11's clinical record, or in the hospice provider's clinical record, that the facility obtained the hospice election of benefits and the certification of terminal illness from the hospice provider. 28 Pa. Code 211.12(d)(3)(5) Nursing Services. 395646 Page 22 of 24 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending August 30, 2023, revealed that the facility developed plans of correction that included development and implementation of abuse and neglect polices, quality of care, and pharmacy services. The results of the current survey, ending June 13, 2024, identified repeated deficiencies related development and implementation of abuse and neglect polices, quality of care, and pharmacy services. The facility's plan of correction for a deficiency regarding development and implementation of abuse and neglect policies, cited during the survey ending August 30, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F607, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding development and implementation of abuse and neglect policies. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending August 30, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care. The facility's plan of correction for a deficiency regarding pharmacy services, cited during the survey ending August 30, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F755, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding pharmacy services. Refer to F607, F684, and F755. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 395646 Page 23 of 24 395646 06/13/2024 Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601
F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on review of a list of nurse aides currently employed by the facility, including their hire dates and training hours, as well as staff interviews, it was determined that the facility failed to ensure that nurse aides had 12 hours of in-service training annually for two of three nurse aides reviewed (Nurse Aide 6, Nurse Aide 7), and failed to ensure that nurse aides received annual in-service training regarding abuse and dementia for one of three nurse aides reviewed (Nurse Aide 6). Findings include: The facility's policy regarding in-services, dated June 7, 2024, indicated that the facility was mandated to ensure that all employees receive training hours required within state and federal guidelines. A list of nurse aides provided by the facility revealed that based on their months and days of hire: Nurse Aide 6 should have received at least 12 hours of in-service training between March 28, 2023, and March 28, 2024. However, there was no documented evidence that she received at least 12 hours of in-service training as required. Nurse Aide 7 should have received at least 12 hours of in-service training between February 26, 2023, and February 26, 2024. However, there was no documented evidence that she received at least 12 hours of in-service training as required. The facility's policy regarding abuse, neglect, exploitation, and misappropriation, dated June 7, 2024, indicated that the facility required staff trainings that included such topics as abuse prevention, identification, reporting abuse, and handling verbally or physically aggressive resident behaviors. Review of personnel records for Nurse Aide 6 revealed a hire date of March 28, 2023. However, there was no documented evidence that she received the facility's annual resident abuse training, abuse reporting training, and dementia training during the time period of March 28, 2023, through March 28, 2024. Interview with the Nursing Home Administrator on June 12, 2024, at 2:40 p.m. confirmed that there was no documented evidence that the above nurse aides received at least 12 hours of in-service training as required or received the facility's annual resident abuse, abuse reporting, and dementia training. 28 Pa. Code 201.20(a) Staff Development. 395646 Page 24 of 24

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Citations

21 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0578GeneralS&S Dpotential for harm

    F578 - The right to request, refuse, and/or discontinue treatment, to participate in or

    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

  • 0582GeneralS&S Dpotential for harm

    F582 - The facility must—

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

  • 0584GeneralS&S Epotential for harm

    F584 - Safe Environment

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  • 0607GeneralS&S Dpotential for harm

    F607 - The facility must develop and implement written policies and procedures that:

    Develop and implement policies and procedures to prevent abuse, neglect, and theft.

  • 0623GeneralS&S Dpotential for harm

    F623 - Transfer and discharge-

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  • 0625GeneralS&S Dpotential for harm

    F625 - Transfer and discharge-

    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

  • 0655GeneralS&S Dpotential for harm

    F655 - Comprehensive Person-Centered Care Planning

    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0686GeneralS&S Dpotential for harm

    F686 - Skin Integrity

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0689GeneralS&S Dpotential for harm

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0695GeneralS&S Dpotential for harm

    F695 - Respiratory care, including tracheostomy care and tracheal suctioning

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0699GeneralS&S Dpotential for harm

    F699 - Trauma-informed care

    Provide care or services that was trauma informed and/or culturally competent.

  • 0730GeneralS&S Epotential for harm

    F730 - Regular in-service education

    Observe each nurse aide's job performance and give regular training.

  • 0755GeneralS&S Epotential for harm

    F755 - Pharmacy Services

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0761GeneralS&S Dpotential for harm

    F761 - Labeling of Drugs and Biologicals

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  • 0801GeneralS&S Dpotential for harm

    F801 - Staffing

    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0842GeneralS&S Dpotential for harm

    F842 - Resident-identifiable information

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0849GeneralS&S Dpotential for harm

    F849 - Hospice services

    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

  • 0867GeneralS&S Dpotential for harm

    F867 - Program feedback, data systems and monitoring

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  • 0947GeneralS&S Dpotential for harm

    F947 - Training Requirements

    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

FAQ · About this visit

Common questions about this visit

What happened during the June 13, 2024 survey of OAK HILL REHABILITATION & HEALTHCARE CENTER?

This was a inspection survey of OAK HILL REHABILITATION & HEALTHCARE CENTER on June 13, 2024. The surveyor cited 21 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at OAK HILL REHABILITATION & HEALTHCARE CENTER on June 13, 2024?

Yes, 21 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate ..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.