Deficiency Records for Oak Hill Center For Rehabilitation and Nursing
Updated as of April 01, 2024
A list of the most recent deficiencies for Oak Hill Center For Rehabilitation and Nursing. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-01-08 | 2024-03-08 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2024-01-08 | 2024-03-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-01-08 | 2024-03-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-08 | 2024-03-08 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-01-08 | 2024-03-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-08 | 2024-03-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-25 | 2024-02-27 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2024-01-25 | 2024-02-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-25 | 2024-02-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-25 | 2024-02-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-25 | 2024-02-20 | N |
| 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. | Health | 2024-01-25 | 2024-02-20 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-01-25 | 2024-02-20 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2024-01-25 | 2024-02-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-25 | 2024-02-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-25 | 2024-02-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-01-25 | 2024-02-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-25 | 2024-02-20 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-01-25 | 2024-02-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-25 | 2024-02-20 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-01-25 | 2024-02-20 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-01-25 | 2024-02-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-25 | 2024-02-20 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-01-25 | 2024-02-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-01-25 | 2024-02-20 | N |
| 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. | Health | 2024-01-25 | 2024-02-20 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2024-01-25 | 2024-02-20 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-01-25 | 2024-02-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-25 | 2024-02-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-25 | 2023-10-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-10 | 2023-07-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-08 | 2023-04-09 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-02-08 | 2023-04-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-09 | 2023-03-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-09 | 2023-03-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-26 | 2023-02-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-01-26 | 2023-02-21 | N |
| 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. | Health | 2023-01-26 | 2023-02-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-26 | 2023-02-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-01-26 | 2023-02-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-26 | 2023-02-21 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-01-26 | 2023-02-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-26 | 2023-02-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-26 | 2023-02-21 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-01-26 | 2023-02-21 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-01-26 | 2023-02-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-01-26 | 2023-02-21 | N |
| 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. | Health | 2023-01-26 | 2023-02-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-26 | 2023-02-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-01-26 | 2023-02-21 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-01-26 | 2023-02-21 | N |
| 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. | Health | 2023-01-26 | 2023-02-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-26 | 2023-02-21 | Y |
| Meet other general requirements. | Fire Safety | 2023-01-12 | 2023-02-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-12 | 2023-02-12 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-01-12 | 2023-02-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-12 | 2023-02-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-12 | 2023-02-12 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-01-12 | 2023-02-12 | N |
| Meet other general requirements. | Fire Safety | 2023-01-12 | 2023-02-12 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-11-22 | 2022-12-08 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-05-06 | 2022-06-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-06 | 2022-06-01 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-01-27 | 2022-03-30 | N |
| 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. | Health | 2022-01-27 | 2022-03-30 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-01-27 | 2022-03-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-27 | 2022-03-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-27 | 2022-03-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-27 | 2022-03-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-27 | 2022-03-30 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-01-27 | 2022-03-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-27 | 2022-03-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-27 | 2022-03-09 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-01-27 | 2022-03-09 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-01-27 | 2022-03-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-27 | 2022-03-09 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-01-27 | 2022-03-09 | N |
| Meet other general requirements. | Fire Safety | 2022-01-06 | 2022-01-21 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-01-06 | 2022-01-21 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-01-06 | 2022-01-21 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-01-06 | 2022-01-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-06 | 2022-01-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-06 | 2022-01-21 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-01-06 | 2022-01-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-06 | 2022-01-21 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2022-01-06 | 2022-01-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-01-06 | 2022-01-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-06 | 2022-01-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-06 | 2022-01-21 | N |
