Oak Hill Center For Rehabilitation And Nursing
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
27, 2025, at 2:08 AM, that Resident 1 was yelling and moaning in pain on right hip area, and was administered 5 milligrams of oxycodone oral tablet. Further review of Resident 1's nursing progress notes revealed a note on August 27, 2025, at 6:58 AM, that the Resident was calling out, can't state her pain level, and was administered 5 milligrams of oxycodone oral tablet for pain. Further review of Resident 1's nursing progress notes revealed a note on August 27, 2025, at 12:35 PM, that the Resident was moaning and unable to walk, and received 5 milligrams of oxycodone oral tablet for pain.Review of Resident 1's clinical record revealed a physician note on August 27, 2025, at 4:06 PM, that read, in part, due to ongoing pain and difficulty ambulating, another x-ray will be ordered to check both right and left hip/femur/knee.On August 27, 2025, at 4:12 PM, there was a nursing progress note that Resident 1 was moaning in pain and was administered 5 milligrams of oxycodone oral tablet. At 7:11 PM, on August 27, 2025, a follow up nursing progress note was documented that the Resident still had a pain level of 4. There was no further documentation in Resident 1's clinical record to indicate any pain intervention or assessment was completed.Review of Resident 1's x-ray patient report dated August 27, 2025, at 11:26 PM, revealed the Resident had an acute fracture of the right sub capital femur.Review of Resident 1's clinical record revealed no documentation of the physician being notified of the Resident's fracture.Review of Resident 1's clinical
record revealed no physician or nursing progress note after the notification of the fracture. There was no additional PRN (as needed) Oxycodone administered after the dose on August 27, 2025, at 4:12 PM.An
interview conducted with the Director of Nursing (DON) on September 8, 2025, at approximately 1:30 PM, revealed x-ray results usually get faxed to the facility, unless it is an unusual finding then they will usually call to confirm it was received by the facility timely. The DON was unable to confirm if a call was received.
The DON revealed she would have expected it to be documented on Resident 1's clinical record when the physician was notified of the positive fracture.Review of a written timeline provided by the DON on September 9, 2025, at 3:32 AM, revealed the provider was made aware of the x-ray results on August 28, 2025, at approximately 8:30 AM, assessed the Resident, and gave orders for the Resident to be sent to the hospital, which occurred at approximately 9:00 AM (Approximately 9.5 hours after the X-ray results came back positive for fracture).Review of Resident 1's clinical record failed to reveal any documentation of a time that EMS (Emergency Medical Services) was called or a time that the Resident was sent to the hospital.
There was also no progress notes documented showing that Resident 1 was assessed for pain or discomfort throughout the evening and night shift.Review of the hospital records revealed Resident 1 was admitted to the hospital and required surgical intervention for the fracture. Resident 1 was administered IV (intravenous line) morphine for pain management until surgery. Review of the clinical record revealed Resident 1 was readmitted to the facility on [DATE REDACTED], after having right hemiarthroplasty surgery (partial hip replacement surgery), with no postop complications.During an interview conducted with the Nursing Home Administrator (NHA) and DON on September 11, 2025, at 12:30 PM, revealed that he would have expected staff to monitor Resident 1 for pain and documenting if any pain assessments were completed prior to the Resident being transferred to the hospital. The facility failed to provide timely transfer to the hospital following confirmation of a femur fracture for Resident 1. The facility also failed to monitor and assess Resident 1 for pain and provide as needed pain medication prior to transfer to the hospital. 42 CFR 483.25 Quality of care28 Pa. Code 211.12(d)(1)(3)(5)Nursing services.
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OAK HILL CENTER FOR REHABILITATION AND NURSING in MIDDLETOWN, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MIDDLETOWN, PA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from OAK HILL CENTER FOR REHABILITATION AND NURSING or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.