Oak Hill Living Center

The facility failed to ensure necessary referral and follow-up for a resident's healthcare needs. Specifically, the facility did not notify the provider that a prescribed seizure medication, Valtoco nasal spray, was unavailable for administration. Although staff reported the missing medication to the Resident Care Director and physician, the medication remained unavailable for use.

The facility failed to ensure that 8 of 8 sampled exit doors had an engaged, audible sounding device for residents who are disoriented or wander. This failure led to a resident exiting the facility unnoticed and being found in the driveway following a fall that required hospitalization.

The facility failed to properly manage health care referrals and follow-up for specific residents. This included issues regarding communication of care obligations for Resident #2, and ensuring timely follow-up or documentation for Resident #1 and Resident #5.

The facility failed to ensure that 8 of 6 sampled exit doors had a continuously sounding device engaged that was audible throughout the facility when opened. This deficiency affected 5 of 6 sampled residents who were documented as disoriented or exhibiting wandering behavior.

The facility failed to meet minimum staffing requirements for 9 out of 94 sampled shifts between 01/28/22 and 02/04/22. Specifically, the facility provided insufficient aide duty hours on various first, second, and third shifts, leaving shifts short-staffed by varying amounts of time.

The facility failed to ensure that aide hours met the minimum staffing requirements for 9 out of 24 sampled shifts between 01/28/22 and 02/04/22. Specifically, the facility did not maintain the required amount of aide duty hours on each 8-hour shift as mandated by the regulation for its capacity.

The facility failed to ensure the health care needs of residents were met, specifically regarding follow-up care and monitoring. Evidence showed a resident with irregular breathing was transferred to the hospital, and the facility failed to properly document vital signs and times during a change in condition.

The facility failed to ensure the health care needs of residents were met, specifically regarding a resident with irregular breathing and a failure to schedule a urology appointment. In one instance, the Resident Care Director failed to notify the physician or call 911 when a resident presented with lethargy, mumbled speech, and irregular respirations. Additionally, there was no documentation of blood pressure checks for the resident during the period of 11/08/21 to 11/11/21.