Oak Hill Healthcare And Rehabilitation Center

F-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

F-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

F-F755.

28 Pa. Code 201.14(a) Responsibility of Licensee.

28 Pa. Code 201.18(e)(1) Management.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 22 395646 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395646 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Hill Rehabilitation & Healthcare Center 827 Georges Station Road Greensburg, PA 15601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0947 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Level of Harm - Minimal harm or potential for actual harm 42079

Residents Affected - Few 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 22 395646