Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oakwood Heights Village during CMS and state inspections, most recent first.
Failure to Respond to Resident Council Concerns: The facility did not document responses or resolution of repeated Resident Council concerns raised over multiple months, including issues with call bells, cleanliness, missing clothing, staffing, room temperatures, and other ongoing complaints. Resident Council members stated they were not receiving responses to prior concerns, and the NHA confirmed there was no evidence the concerns were resolved or that the council was informed of the outcomes.
The facility failed to ensure residents had timely access to petty cash and could obtain funds the same day for small amounts, including on weekends. Residents reported they had to give at least 24-hour notice for cash requests, the NHA confirmed the petty cash box was kept in the Business Office and could not be accessed on weekends, and an observation found the box nearly depleted with old receipts and resident checks inside.
Failure to Maintain Clean Resident Rooms: Multiple resident rooms on the first and third floors had a removable black substance covering large areas of the bedroom and bathroom floors. The facility’s policy and admission agreement stated residents would receive a safe, clean, and homelike environment, and the room cleaning process required daily housekeeping tasks such as sweeping and mopping floors and cleaning bathroom surfaces. An ES Mgr and an LPN both confirmed the substance was present and could be removed with minimal effort.
Failure to provide bed-hold notice and transfer information: The facility did not document that required clinical information was sent to the receiving provider when four residents were transferred to the hospital, and did not show that the bed-hold policy was given to the resident and/or representative for three residents. The residents had diagnoses including DM, PVD, HTN, chronic respiratory failure, CHF, dementia, GERD, COPD, and anxiety; the DON confirmed the missing documentation.
Improper oxygen administration and storage of respiratory equipment: A resident with chronic respiratory failure was observed receiving O2 at a higher flow rate than ordered, and another resident’s nasal cannula was found on the floor while connected to the concentrator. Several other residents with COPD, HF, and other chronic conditions had O2 tubing and cannulas left on the floor or hanging over equipment instead of being stored in plastic bags when not in use, as confirmed by RN, LPN, and the DON.
Physician orders were not signed and dated at required intervals for nine residents. The records showed gaps beyond the 60-day timeframe for residents with conditions such as Alzheimer’s disease, DM, COPD, CHF, HTN, CKD, asthma, anxiety, GERD, and AFib. The DON confirmed the orders were not reviewed and signed within the required schedule.
Resident personal and medical records were not kept private on the Third floor 100 hall med cart. An open computer displaying resident health information was left facing the hallway while an LPN walked away from the cart several times, and visitors, residents, and staff passed by the visible record. The LPN confirmed the computer was left open and the information was not covered.
Failure to Document Non-Pharmacological Interventions Before PRN Psychotropic Use: A resident with Alzheimer's disease, diabetes, and muscle weakness had a PRN lorazepam order for anxiety, and the MAR showed multiple administrations of the medication. The clinical record lacked evidence that non-pharmacological interventions were attempted before each PRN dose, and the DON confirmed the missing documentation.
Physician visit requirements were not met for two residents. One resident’s initial assessment was completed by the NP instead of the physician, and another resident’s record lacked evidence of a physician visit for an extended period, with multiple progress notes signed by the NP. The DON confirmed the missing physician visit information and that the initial visit for the other resident was done by the NP.
An LPN left a medication cart unlocked and out of view while preparing meds, and two other carts contained outdated or improperly labeled medications. A Trelegy Ellipta inhaler and an open vial of Aspart insulin lacked open dates, and loose pills were found in cart drawers; staff confirmed the items should have been discarded.
Food storage and sanitation standards were not followed in the main kitchen and a First-Floor pantry refrigerator. An observation found opened salsa, grated parmesan cheese, and sweet relish with no open dates in the walk-in cooler, and the Dietary Manager confirmed they should have been dated when opened. A separate observation found dried brown/tan liquid in the pantry refrigerator, and Housekeeping confirmed the condition.
The facility failed to ensure the Medical Director carried out responsibilities to develop, review, and improve resident care policies. The Medical Director agreement stated the MD was to guide, approve, and oversee resident care policies and procedures, but the annual policy review had no MD signature. The NHA stated the MD was not present throughout the year and was not part of the annual policy review.
The facility failed to ensure the Medical Director or designee attended required quarterly QAPI meetings. Review of the QAPI policy showed the committee had to include the Medical Director or designee, but attendance records for four quarterly meetings showed no evidence of their presence. The NHA confirmed the facility lacked evidence of the required attendance.
Inaccurate MDS Coding for Hospice and Discharge Status: The facility failed to accurately code MDS assessments for three residents. Two residents had hospice orders that were coded incorrectly on the MDS, and one resident’s discharge MDS did not match the documented discharge to another facility. The RNAC confirmed the coding errors.
A resident with multiple diagnoses, including dementia and diabetes, did not receive premedication with both PRN Lorazepam and Morphine prior to care as ordered by the physician. Facility staff failed to accurately transcribe the physician's order, resulting in the omission of instructions to administer both medications together before care. Documentation showed the resident was repositioned multiple times without evidence of the required premedication, and nursing notes indicated increased discomfort and anxiety during care.
A resident with diabetes, dementia, and hypertension did not have complete and accurate documentation of oral hygiene care in their clinical record, as required by facility policy. Multiple shifts and days showed missing or 'not applicable' entries for oral care, and the DON confirmed the lack of proper documentation.
A resident with Alzheimer's Disease and Parkinsonism, who was non-verbal and required two-person assistance for bed mobility, was injured when an agency CNA attempted to reposition the resident alone, contrary to the care plan. The resident fell from bed, sustaining a forehead laceration and an intraventricular hemorrhage. Staff interviews confirmed the two-person assist requirement was documented and known, but not followed, resulting in actual harm.
A resident with significant cognitive and physical impairments, who required two staff for bed mobility, was rolled in bed by a single agency CNA, contrary to the care plan and task orders. This resulted in the resident falling from bed, sustaining a forehead laceration and an intraventricular hemorrhage. The CNA was unaware of the resident's need for two-person assistance and did not follow established protocols, leading to actual harm.
A resident suffered a head laceration requiring staples after being incorrectly transferred with an oversized sling using a Hoyer lift. The facility lacked a process to ensure proper sling sizing, leading to the resident slipping through the sling. Staff interviews confirmed the absence of documentation for correct sling size in the resident's records.
The facility failed to maintain food safety and sanitation standards, with expired food items found in the kitchen and pantries, and improper labeling and storage practices. Additionally, a homemaker employee did not follow proper hygiene protocols during food handling. These issues were confirmed by staff, indicating non-compliance with facility policies.
A facility failed to document a clinical rationale and duration for the continued use of a PRN psychotropic medication beyond 14 days for a resident with multiple health conditions. The resident's orders for Lunesta, a sleeping pill, lacked the required stop date and justification for extended use, as confirmed by an LPN, violating facility policy and regulatory requirements.
The facility did not label multi-dose insulin vials with the date they were opened, nor did it discard expired vials on the third-floor medication cart A. The policy requires vials to be dated upon opening and discarded after 28 days. An LPN confirmed the requirement to date vials to ensure timely disposal.
The facility failed to meet the required nurse aide (NA) staffing ratios over a 14-day period, with shortages noted on multiple days and shifts. The facility did not maintain the minimum staffing levels of one NA per 10 residents during the day, one NA per 11 residents during the evening, and one NA per 15 residents overnight. The Nursing Home Administrator confirmed these deficiencies.
The facility did not meet the required 3.2 hours of direct resident care per day on six occasions, with the lowest being 2.64 hours. This was confirmed by the Nursing Home Administrator.
The facility failed to provide timely medication delivery for three residents, resulting in missed doses of essential medications. A resident with epilepsy missed doses of Lacosamide, another with pneumonia missed doses of Cefazolin, and a third with an infection missed doses of Piperacillin. The Director of Nursing confirmed the delays in pharmacy delivery, which were not in line with the facility's policy on medication availability.
A resident with diabetes was incorrectly administered Novolog insulin instead of the prescribed Novolog 70/30 mix insulin upon admission to the LTC facility. This error went unnoticed for several weeks, leading to an incident where the resident was found clammy and sweaty with low blood glucose levels. The mistake was confirmed by an RN and corrected after discovery.
The facility failed to provide an environment that enhances the quality of life for a resident with multiple diagnoses, including dementia and bipolar disorder. Despite the resident's expressed desire for social interaction, they were observed multiple times sitting alone in their room without personal interactions. Interviews with the DON and Director of Activities confirmed that the resident should not be left alone for extended periods.
The facility failed to follow essential safety measures, resulting in falls for two residents. One resident was pushed in a wheelchair without leg rests, causing a fall, while another was transferred by one staff member instead of the required two, leading to a fall.
A facility failed to provide appropriate care for a resident with a urinary catheter. Observations showed the urinary drainage bag lying flat on the floor with the drainage spout touching the floor. An LPN confirmed that the bag should not be on the floor and should have a privacy cover. The resident had a history of UTI, hypertension, and hyperlipidemia.
Failure to Respond to Resident Council Concerns
Penalty
Summary
The facility failed to respond to resident concerns identified during Resident Council meetings for three consecutive months, including November 2025, December 2025, and January 2026. Facility policy stated that a Resident Council Response Form would be used to track issues and their resolution and that the department related to each concern would be responsible for addressing it, but there was no evidence that this process was used. During an interview, Resident Council members stated they did not receive responses to prior concerns and did not believe concerns were resolved in a timely manner because of the number of ongoing issues raised by the group. Review of the meeting minutes showed repeated concerns that were not documented as resolved or discussed from one month to the next. Issues included a leaking faucet, broken call bell, missing clothing, dirty floors and bathrooms, windows needing cleaning, staff not wearing name tags, requests for help in the dining room, a beautician leaving, poor floor care, wrinkled clothing, call bell response times, staffing, activities, room temperatures, and Administrator participation in meetings. The Nursing Home Administrator confirmed there was a lack of evidence that repeated concerns from Resident Council and Concern, Comment, Procedure Forms were resolved, and there was a lack of evidence that the Resident Council was informed of the outcomes or satisfied with them.
Resident Access to Petty Cash Not Available Same Day or on Weekends
Penalty
Summary
The facility failed to ensure residents had ongoing access to petty cash and failed to ensure residents could obtain funds from the resident petty cash fund the same day for amounts under $100.00, or under $50.00 for Medicaid residents, and on weekends for all 89 of 89 residents. The facility’s Admissions Agreement stated that cash would be provided within one day of request or a check within three days of request, but residents reported they could not access petty cash the same day during the week and could not access it at all on weekends. Residents stated they had to give at least 24-hour notice for cash requests so the NHA could go to the bank. During interviews, the NHA confirmed the cash box contained $400 and was kept in the Business Office, with residents signing a receipt for the amount requested and the BOM issuing a check to the NHA to cash and replenish the petty cash box. The NHA also confirmed there was no one in the building on weekends to access petty cash for resident requests. Observation of the petty cash box showed only a $5 bill, a few $1 bills and change, receipts, and resident checks dated in December. The NHA further confirmed having had a check to take to the bank since the prior week but not yet cashing it. A facility checking account statement showed a $400 check issued to the NHA on 1/23/26.
Failure to Maintain Clean Resident Rooms
Penalty
Summary
The facility failed to provide housekeeping services necessary to maintain a clean environment in multiple resident rooms on the first floor and third floor. Review of the facility’s Homelike Environment policy stated residents are to be provided with a safe, clean, comfortable, and homelike environment, and the admission agreement stated the facility would provide clean lodging. The facility’s Room Cleaning Process identified daily housekeeping tasks including removing trash, sweeping and mopping floors, and cleaning bathroom surfaces and toilets. Observations on the first floor showed resident rooms 101, 102, 103, 104, 105, 107, 108, 109, 111, and 113 had a removable build-up of a black substance covering much of the bedroom and bathroom floors. The Environmental Services Manager confirmed the black substance was present and could be removed with minor effort. Observations on the third floor showed resident rooms 303, 304, 305, 309, 316, and 317 had large areas of a dry black substance on the bedroom and bathroom floors, and an LPN confirmed the substance was present and removable with minimal effort.
Failure to Provide Bed-Hold Notice and Transfer Information
Penalty
Summary
The facility failed to provide residents and/or their representatives with a written notice of the facility bed-hold policy and failed to ensure that necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for four of four residents reviewed: R11, R12, R76, and R90. The facility policy titled Transfer and Discharge stated that a notice of transfer and the facility's bed-hold policy must be provided to the resident and representative, and that for a transfer to another provider, information including practitioner contact information, resident representative information, advance directive information, special instructions, precautions, resident status, diagnoses, allergies, medications, and relevant labs must be sent to the receiving provider. R11, admitted with diabetes, peripheral vascular disease, and hypertension, had progress notes showing hospital transfers on 9/3/25 and 9/20/25, but the record lacked evidence that necessary clinical information was communicated to the receiving provider and lacked evidence that the resident and/or representative received a copy of the bed-hold policy on 9/20/25. R12, admitted with chronic respiratory failure, diabetes, and congestive heart failure, had hospital transfers documented on 4/8/25, 9/6/25, 10/14/25, and 10/21/25, but the record lacked evidence that necessary clinical information was communicated to the receiving provider and lacked evidence of bed-hold policy notification on 9/6/25 and 10/14/25. R76, admitted with dementia, hypertension, and GERD, had hospital transfers documented on 12/26/25 and 1/31/26, but the record lacked evidence that necessary clinical information was communicated to the receiving provider and lacked evidence of bed-hold policy notification on 12/26/25. R90, admitted with COPD, anxiety, and diabetes, had a hospital transfer documented on 11/18/25, but the record lacked evidence that necessary clinical information was communicated to the receiving provider. The DON confirmed during interview that the records lacked evidence of the required communication and bed-hold policy notification.
Improper oxygen administration and storage of respiratory equipment
Penalty
Summary
The facility failed to maintain proper care of respiratory equipment and failed to provide oxygen according to physician orders for seven residents receiving respiratory care. Facility policy stated that oxygen is administered under physician orders and that delivery devices are to be kept covered in a plastic bag when not in use. Resident R12, who had chronic respiratory failure, diabetes, and congestive heart failure, had an order for oxygen at 2 liters per minute via nasal cannula every shift, but was observed with the concentrator set at 3 liters per minute. Resident R19, who had COPD, heart failure, and hyperlipidemia, was observed with the nasal cannula prongs lying on the floor while the tubing remained connected to the oxygen concentrator. Resident R22, with heart disease/failure, COPD, and Type 2 diabetes, had an order for oxygen at 2 liters per minute at night, but the tubing and nasal cannula were observed hanging over the top of the concentrator and not in a plastic bag. Similar observations were made for Resident R25, who had COPD, Type 2 diabetes, a communication deficit, and seizures, with oxygen ordered at 4 liters per minute every shift; Resident R29, who had Type 2 diabetes, heart failure, difficulty swallowing, and long-term kidney disease, with oxygen ordered at 2 liters per minute as needed; Resident R50, who had respiratory failure, COPD, irregular heartbeat, and heart failure, with oxygen ordered at 2 liters per minute as needed; and Resident R56, who had COPD, Alzheimer’s disease, asthma, and an irregular heartbeat, with oxygen ordered at 2 liters per minute every night. Their oxygen tubing and nasal cannulas were observed either lying on the floor or hanging over equipment and not stored in plastic bags. RN and LPN staff confirmed the incorrect oxygen flow rate for R12, the cannula on the floor for R19, and that the tubing and cannulas for R22, R25, R29, R50, and R56 should have been stored in plastic bags when not in use.
Physician Orders Not Signed and Dated at Required Visits
Penalty
Summary
The facility failed to ensure that the physician signed and dated all orders during required visits for nine of 21 residents reviewed: R4, R7, R10, R18, R19, R22, R23, R58, and R67. Facility policy stated that the physician should see a resident within 30 days of admission, see the resident at least every 30 calendar days for the first 90 days after admission and at least every 60 days thereafter, and sign and date all orders. Review of the clinical records showed that each of the affected residents had physician orders signed and dated on 9/12/25 and then not again until 1/26/26, which was beyond the required 60-day interval. The residents involved had multiple chronic conditions, including Alzheimer’s disease, diabetes, muscle weakness, asthma, anxiety, hypertension, COPD, chronic kidney disease, heart failure, hyperlipidemia, GERD, and atrial fibrillation. The record review documented admission dates ranging from 11/26/18 to 10/19/25. During an interview on 2/5/26 at 2:06 p.m., the DON confirmed that physician orders for these residents were not reviewed and signed by the physician within the required 60 days and stated that orders should be reviewed and signed with every physician visit on admission, then every 30 days for the first 90 days, and every 60 days thereafter.
Resident Information Left Visible on Medication Cart
Penalty
Summary
Resident personal and medical records were not kept private and confidential on one of five medication carts, specifically the Third floor 100 hall medication cart. Facility policy dated 1/28/26 stated that computer screens are to be in privacy mode or hidden when administering medications. During observations on 2/3/26 between 12:30 p.m. and 12:50 p.m., the medication cart was observed sitting in the hallway against the wall with an open computer on top of the cart and resident health information visibly facing into the hallway. The LPN returned and walked away from the cart several times while the resident health information remained visible as several visitors, residents, and staff walked past the viewable health record. During interview at 12:50 p.m., the LPN confirmed leaving the cart with the computer open and not covering the resident health information, and confirmed that resident information should be covered when not within view.
Failure to Document Non-Pharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
The facility failed to provide evidence that non-pharmacological interventions were attempted before administering PRN lorazepam to one resident. The resident was admitted on 11/26/18 with diagnoses including Alzheimer's disease, diabetes, and muscle weakness. On 12/2/25, the physician ordered lorazepam 0.5 mg every 4 hours PRN for anxiety, and the resident received the medication on 12/8/25, 12/16/25, 12/21/25, 1/2/26, 1/14/26, 1/15/26, 1/17/26, and 1/22/26. Review of the resident's December 2025 and January 2026 MARs and clinical record showed no evidence that non-pharmacological interventions were attempted before each of the eight PRN administrations. During an interview on 2/5/26 at 10:56 a.m., the DON confirmed that the record lacked documentation of non-pharmacological interventions prior to the PRN psychotropic medication administrations and stated that such interventions should be attempted and documented in the clinical record.
Physician Visit Requirements Not Met
Penalty
Summary
The facility failed to ensure that the resident’s initial physician visit was completed by the physician and failed to ensure that required resident visits were alternated between the physician and the nurse practitioner or physician assistant for two residents. Facility policy stated that the physician should see the resident within 30 days of admission and sign a progress note for each visit, and that after the initial visit, required skilled nursing facility visits may alternate between the physician and a physician assistant, nurse practitioner, or clinical nurse specialist. Resident R29 was admitted with diagnoses including Type 2 diabetes, heart failure, difficulty swallowing, and muscle weakness. The clinical record showed that on 1/25/26, the initial assessment was completed by the nurse practitioner rather than the physician. Resident R22 was admitted with diagnoses including heart disease/heart failure, Type 2 diabetes, and COPD, and the record lacked evidence that the resident had been seen by the physician since 1/31/25. Provider progress notes for R22 were completed and signed by the nurse practitioner on 3/18/25, 5/20/25, 6/17/25, and 8/26/25. During interview, the DON confirmed that the most recent physician visit for R22 could not be determined and that R29’s initial visit was conducted by the nurse practitioner.
Medication Labeling and Cart Security Deficiencies
Penalty
Summary
Drugs and biologicals were not consistently labeled and stored in accordance with facility policy and accepted professional principles. Review of the First-floor rehab medication cart on 2/3/26 found a Trelegy Ellipta Diskus out of its foil package, in use, and lacking an open date. The LPN present confirmed the inhaler lacked an open date and that staff could not determine the discard date; the LPN also confirmed it should have been discarded. Facility policy required the date opened to be recorded on multi-dose containers, and manufacturer guidance stated Trelegy Ellipta should be discarded six weeks after opening the foil tray or when the counter reads 0, whichever comes first. Review of the Second-floor medication cart on 2/3/26 found an open vial of Aspart insulin without an open date, and several loose random pills in the second and third drawers of the cart. The LPN present confirmed the insulin vial lacked an open date, staff could not determine the discard date, and the loose pills should have been discarded. Observation of the Third floor 100 hall medication cart showed an LPN preparing medications while the cart was parked in the hall with drawers facing into the hallway; the LPN walked away from the cart into resident rooms and the pantry several times without securely locking it and could not view it from those areas. The LPN confirmed the cart was left unlocked while out of view and that it should have been locked when not visible.
Food Storage and Refrigerator Sanitation Deficiencies
Penalty
Summary
Food was not stored in accordance with food safety standards in the main kitchen and sanitary conditions were not maintained in one of three pantry refrigerators on the First Floor. Review of the facility policy dated 1/28/26 stated that all foods stored in the refrigerator or freezer must be covered, labeled, and dated, and that dining services or other designated staff would maintain clean food storage areas at all times. During observation on 2/03/26 at 9:30 a.m. in the main kitchen walk-in cooler, two 48-ounce bottles of salsa, three 16-ounce jars of grated parmesan cheese, and one bottle of sweet relish were found with no open dates. The Dietary Manager later confirmed that these items should have been dated when opened. During a separate observation on 2/03/26 at 10:45 a.m., the First-Floor pantry refrigerator was found with brown/tan dried liquid on the bottom floor of the main compartment and on the bottom shelf of the door, and Housekeeping Employee E1 confirmed those conditions.
Medical Director Not Involved in Annual Policy Review
Penalty
Summary
The facility failed to ensure that the Medical Director fulfilled responsibilities to develop, review, and improve resident care policies. Review of the Medical Director agreement showed that the Medical Director was expected to guide, approve, and help oversee the development, implementation, and monitoring/evaluation of the facility’s resident care policies and procedures in several areas. However, review of the facility’s annual policy reviews dated 1/28/26 revealed no signature by the Medical Director. During interview, the Nursing Home Administrator stated that the Medical Director was not present at the facility throughout the year to fulfill the responsibility for development, review, and improvement of resident care policies and was not part of the annual policy review.
Missing Required Medical Director Attendance at QAPI Meetings
Penalty
Summary
The facility failed to ensure the required attendance of the Medical Director or his/her designee at Quality Assurance and Performance Improvement (QAPI) Committee meetings for four of four quarterly meetings reviewed. Review of the facility policy entitled Quality Assurance and Performance Improvement dated 1/28/26 showed that the QAA Committee was required to be interdisciplinary and include, at a minimum, the Medical Director or his/her designee. Review of the QAPI Committee attendance records from March 2025 through December 2025 showed no evidence on the attendance sign-in sheets that the Medical Director or his/her designee attended the required quarterly QAPI meetings. During an interview on 2/06/26 at approximately 10:30 a.m., the Nursing Home Administrator confirmed that the facility lacked evidence that the Medical Director or his/her designee attended the quarterly QAPI Committee meetings as required.
Inaccurate MDS Coding for Hospice and Discharge Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three of 21 residents reviewed, resulting in MDS assessments that did not reflect the residents’ status. Resident R11 was admitted with diagnoses including diabetes, peripheral vascular disease, and hypertension, and had a physician order for hospice with a start date of 12/30/25; however, the MDS dated [DATE] incorrectly coded hospice as yes. Resident R23 was admitted with diagnoses including heart failure, hypertension, and atrial fibrillation, and had a physician order for hospice with a start date of 10/25/24; however, the MDS dated [DATE] incorrectly coded hospice as no. Resident R90 was admitted with diagnoses including chronic obstructive pulmonary disease, anxiety, and diabetes, and the discharge recapitulation of stay dated 12/15/25 indicated the resident was admitted to another facility. The resident’s MDS submissions included a discharge return anticipated dated 11/18/25, but there was no evidence that a discharge return not anticipated MDS was completed. During interviews, the RNAC confirmed that Residents R11 and R23 were coded inaccurately for hospice services and that Resident R90’s discharge MDS was coded inaccurately.
Failure to Accurately Transcribe and Administer Premedication Orders for Comfort
Penalty
Summary
The facility failed to accurately transcribe and implement a physician's order for premedication to promote comfort and prevent discomfort during care for one resident. The physician's order specified that the resident should be premedicated with Ativan (Lorazepam) 0.5 mg and Morphine 10 mg every two hours as needed prior to care. However, the facility's transcribed orders did not include the instruction to administer both medications together prior to care, and the Morphine order lacked the premedication instruction entirely. Review of the Medication Administration Record (MAR) and nursing documentation showed that the resident was repositioned multiple times, but there was no evidence that both PRN Lorazepam and PRN Morphine were administered together as ordered before care was provided. The resident, who had diagnoses including diabetes, dementia, and hypertension, was observed to experience increased discomfort, moaning, and anxiety during repositioning and incontinence care, as documented in nursing progress notes. Staff interviews confirmed that the orders were not transcribed as written by the physician, and the Director of Nursing acknowledged the omission. Facility policy required that PRN medication orders specify the reason for administration and symptoms for which the medication is prescribed, but these requirements were not met in this case.
Incomplete Documentation of Oral Hygiene Care
Penalty
Summary
The facility failed to maintain complete and accurate documentation of oral hygiene care for one resident. According to the facility's mouth care policy, the date and time of mouth care should be recorded in the resident's clinical record. Review of the clinical record for a resident with diagnoses including diabetes, dementia, and hypertension revealed multiple instances across various shifts where documentation of oral care was missing or marked as not applicable. Specifically, there were several days and shifts where no record indicated that oral hygiene was completed. The Director of Nursing confirmed during an interview that the clinical record lacked complete documentation for oral hygiene and acknowledged that such care should be performed and documented as ordered.
Failure to Follow Two-Person Assist Care Plan Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease, Parkinsonism, and muscle weakness, who was non-verbal and totally dependent on two staff for bed mobility and repositioning, was not provided care according to their established care plan. The resident's care plan and task orders clearly indicated that two staff members were required to assist with rolling and repositioning in bed. Despite this, an agency CNA attempted to roll the resident independently during morning care, without seeking assistance or following the documented care instructions. During the attempted repositioning, the resident rolled out of bed and struck their head on the roommate's bed frame, resulting in a 3 cm laceration to the right forehead and subsequent bruising. The resident was found to be in significant pain and was later transferred to the hospital, where a CT scan revealed a small, acute bilateral intraventricular hemorrhage. The resident's non-verbal status prevented them from providing any account of the incident. Staff interviews confirmed that the resident always required two-person assistance for bed mobility, and this information was accessible in the task orders. The agency CNA involved acknowledged in a written statement that they were unaware of the resident's stiffness and did not receive information about the need for two-person assistance. The incident was witnessed by another CNA, who found the resident partially out of bed and bleeding. The facility's investigation confirmed that the agency CNA did not follow the care plan or task orders, resulting in actual harm to the resident.
Failure to Provide Required Assistance During Bed Mobility Results in Resident Harm
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease, Parkinsonism, and muscle weakness, who was non-verbal and totally dependent on two staff for bed mobility, was not provided the required level of assistance during repositioning in bed. The resident's care plan and task orders clearly indicated that two staff were needed for rolling side to side, and this requirement was documented in multiple reviews and confirmed by staff interviews. Despite these documented requirements, an agency CNA attempted to roll the resident independently without assistance. During this process, the resident rolled out of bed and struck their head on the roommate's bed frame, resulting in a 3 cm laceration to the right forehead and subsequent bruising. The incident was witnessed by another CNA who responded to noises from the room and found the resident partially out of bed and the agency CNA attempting to assist them back onto the bed. Following the incident, the resident was assessed and found to have a significant laceration and was in considerable pain. A CT scan at the hospital revealed a small acute bilateral intraventricular hemorrhage. The agency CNA involved stated they were unaware of the resident's stiffness and did not know that two staff were required for the task. The failure to follow the care plan and task orders for bed mobility assistance directly resulted in actual harm to the resident.
Failure to Ensure Proper Sling Sizing Leads to Resident Injury
Penalty
Summary
The facility failed to maintain a safe environment for Resident R46 by not ensuring the correct sizing of a mechanical lift sling, which resulted in actual harm. Resident R46, who was dependent on staff for transfers and cognitively intact, was incorrectly transferred using a Hoyer lift with an extra-large sling instead of the appropriate medium size. This error led to the resident slipping through the sling, causing a head laceration that required staple repair. The facility's policy on Safe Resident Handling/Transfers mandates proper sling sizing, but this was not adhered to in this instance. Interviews with staff revealed a lack of process or documentation in the resident's clinical record to indicate the correct sling size for transfers. The Director of Nursing confirmed the inappropriate use of the sling size and acknowledged the absence of a process to ensure proper sling size determination. This deficiency was identified through a review of facility policy, investigation documents, clinical records, and staff interviews, highlighting a failure in the facility's management and nursing services as per the cited Pennsylvania Code regulations.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to its own policies regarding food safety and sanitation, as evidenced by several observations during a kitchen tour and pantry inspections. In the main kitchen, multiple food items were found stored beyond their use-by dates, including barbecue pork, chili, hard-boiled eggs, potato salad, coleslaw, and yogurt. These items were confirmed by a dietary employee to be past their expiration and should have been discarded. Additionally, in the First Floor pantry, a jar of homemade jelly was found without a resident name and with an open date from several months prior, and ice packs used for resident treatments were improperly stored with food items. On the Third Floor, a loaf of homemade bread and a pizza box lacked proper labeling with resident names or dates. During a tray line observation, a homemaker employee failed to maintain proper hygiene practices by not changing gloves or washing hands after handling various items before touching residents' food. This was confirmed by the employee, who acknowledged the lapse in protocol. The Director of Nursing and the Dietary Manager confirmed the deficiencies in labeling, storage, and hygiene practices, which were not in compliance with the facility's policies and professional standards for food safety.
Failure to Document Rationale for Extended PRN Psychotropic Use
Penalty
Summary
The facility failed to provide a clinical rationale and duration for the continued use of a PRN psychotropic medication beyond 14 days for a resident. The facility's policy on the use of psychotropic medications requires that PRN orders be limited to no more than 14 days unless there is documented justification from a physician or prescriber for an extended period. However, the clinical records for a resident, who was admitted with diagnoses including diabetes, heart failure, and chronic obstructive pulmonary disease, showed a physician's order for Lunesta, a sleeping pill, initially prescribed at 1 mg and later increased to 2 mg as needed at bedtime. These orders did not include the required stop date within 14 days or a clinical rationale for continuation beyond this period. During an interview, an LPN confirmed that the orders for the resident's Lunesta lacked the necessary stop date and clinical rationale for continued use beyond 14 days. This oversight was in violation of the facility's policy and the regulatory requirement that PRN psychotropic medications should have a documented rationale and specified duration if used beyond the standard 14-day limit.
Failure to Label and Discard Expired Insulin Vials
Penalty
Summary
The facility failed to adhere to its policy regarding the labeling and timely disposal of multi-dose insulin vials. During a review, it was found that a multi-dose vial of Novolog insulin on the third-floor medication cart A was opened but not labeled with the date it was opened. Additionally, the cart contained two vials of opened Novolog insulin that were undated, despite being stored in a bag with an expiration date. The facility policy requires that multi-dose vials be labeled with the date they are opened and discarded 28 days thereafter. An LPN confirmed that the vials should be dated upon opening to ensure timely disposal and prevent usage past expiration.
Staffing Deficiencies in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios as mandated by regulations effective July 1, 2024. Specifically, the facility did not maintain the minimum staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents overnight. This deficiency was observed over a 14-day period from January 1, 2025, to January 14, 2025. During this time, the facility was short-staffed on eight days for the day shift, two days for the evening shift, and six days for the overnight shift. The census of residents varied slightly, ranging from 82 to 86 residents, but the facility consistently failed to provide the required number of NAs to meet the staffing ratios. The specific shortages included instances where the number of NAs working was below the required number, such as on January 1, 2025, when only 7.09 NAs worked during the day shift, while 8.60 were required for a census of 86 residents. Similar shortages were noted on other days and shifts, with the most significant shortfall occurring on the overnight shift on January 4, 2025, where only 3.40 NAs worked, while 5.60 were required. The Nursing Home Administrator confirmed these staffing deficiencies during a telephone interview, acknowledging the facility's failure to meet the minimum NA ratio requirements on the specified dates and shifts.
Plan Of Correction
The facility acknowledges that, as of 1/21/2024, we are unable to change the results of the staffing ratio of nurse aides of one NA per 10 residents on the day shift for eight of 14 days reviewed (1/01/25, 1/02/25, 1/04/25, 1/05/25, 1/06/25, 1/07/25, 1/11/25, and 1/13/25); failed to ensure a minimum of one NA per 11 residents for the evening shift for two of 14 days reviewed (1/05/25, and 1/06/25); and failed to ensure a minimum of one NA per 15 residents for the overnight shift for six of 14 days reviewed (1/04/25, 1/05/25, 1/07/25, 1/09/25, 1/12/25 and 1/14/25). The upcoming schedules are created by the scheduler and reviewed with the Director of Nursing (DON) and Administrator for approval. Instruction has been provided to the DON, Scheduler, and Nursing Supervisors to ensure that they know how staffing ratios are met in creating schedules and deal with call-offs. Oakwood has advanced a recruitment and retention effort to entice additional employees to us and keep the ones that we hire. The facility has also acquired agency staff to augment our staff. Bonuses and incentives are offered to staff who pick up shifts and stay overtime. The Administrator performs a spot audit of schedules versus actual hours of care to track adherence to regulations. This will be applied to at least three days a week to ensure that staffing ratios are within prescribed parameters. The results of the audits will be provided to the Quality Assurance and Performance Improvement (QAPI) Committee for the next three meetings.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period on six specific days within a two-week period. The review of nursing staffing documents revealed that the facility provided less than the required hours of care on January 1st, 3rd, 4th, 5th, 6th, and 8th of 2025, with the lowest being 2.64 hours per patient per day on January 5th. This deficiency was confirmed by the Nursing Home Administrator during a telephone interview, acknowledging the shortfall in meeting the mandated care hours on the specified dates.
Plan Of Correction
The facility acknowledges that, as of 1/21/2025, the facility failed to provide the minimum number of general nursing care hours of 3.2 hours of direct resident care hours per resident in a twenty-four-hour period for six of 14 days reviewed (1/01/25, 1/03/25, 1/04/25, 1/05/25, 1/06/25 and 1/08/25). The upcoming schedules are created by the scheduler and reviewed with the Director of Nursing (DON) and Administrator for approval. Instruction has been provided to the DON, Scheduler, and Nursing Supervisors to ensure that they know how to achieve a 3.2 hours PPD in creating schedules and deal with call-offs. Oakwood has advanced a recruitment and retention effort to entice additional employees to us and keep the ones that we hire. The facility has also acquired agency staff to augment our staff. Bonuses and incentives are offered to staff who pick up shifts and stay overtime. The Administrator performs a spot audit of schedules versus actual hours of care to track adherence to regulations. This will be applied to at least three days a week to ensure that staffing ratios are within prescribed parameters. The results of the audits will be provided to the Quality Assurance and Performance Improvement (QAPI) Committee for the next three meetings.
Failure to Ensure Timely Medication Delivery
Penalty
Summary
The facility failed to ensure the timely availability of medications for three residents, resulting in missed doses. Resident R1, diagnosed with epilepsy, cerebral palsy, and major depressive disorder, had a physician's order for Lacosamide, an anticonvulsant medication, which was not administered as ordered on four occasions due to delays in pharmacy delivery. Similarly, Resident R2, with diagnoses including pneumonia and chronic obstructive pulmonary disease, missed four doses of Cefazolin Sodium Injection Solution, an antibiotic, because the facility was waiting for the pharmacy to deliver the medication. Resident R3, who had an infection of an amputation stump and a malignant neoplasm, was prescribed Piperacillin Sodium Tazobactam Sodium Solution, another antibiotic, but missed six doses due to the same issue of delayed pharmacy delivery. The Director of Nursing confirmed that the medications for these residents were not provided in a timely manner, leading to the missed doses. The facility's policy on medication delivery was not adhered to, as emergency deliveries were not utilized to ensure timely administration of medications.
Plan Of Correction
Intervention with regard to R1, R2 and R3: We have reviewed the case files of these residents and have determined that there were no adverse effects experienced due to the events cited. Interventions for all residents: 1. All residents' medications were reviewed by the pharmacist to ensure medications were present in the facility and made an urgent request to pharmacy in the event that medications that were not available. 2. New Admissions will be reviewed by Director of Nursing (DON) or designee to ensure medications were delivered as per order on next business day. 3. Review of the in-house medication storage and distribution vault (aka Cubex) was completed on January 15, 2025 and medication Cefazolin was added to the Cubex. 4. All licensed staff will be educated by the DON or designee on admission process for new medications to include medication in Cubex, calling pharmacy for late admissions, printing orders and faxing to pharmacy for controlled substances. They will also be trained on the medication re-ordering process in order to mitigate lapsed medication orders. Monitoring of the change to sustain system compliance ongoing: The DON/designee will monitor medication orders 5 times a week for 4 weeks to ensure medications are available to administer then monthly for 2 months and ongoing. Findings will be reported to Quality Assurance and Performance Improvement (QAPI) committee for review and recommendations.
Medication Administration Error for a Resident
Penalty
Summary
The facility failed to provide the highest practicable care regarding correct medication administration for a resident, identified as Resident R1. Resident R1 was admitted with diagnoses including diabetes, kidney disease, and high blood pressure. On June 25, 2024, Resident R1 was observed to be clammy and sweaty with a low blood glucose level. A review of the facility's investigation into the medication error revealed that Resident R1 was supposed to receive Novolog 70/30 mix insulin, which they had been using at home. However, upon admission to the facility, they were incorrectly administered Novolog insulin instead. This error persisted from the admission date of June 5, 2024, until June 26, 2024, when the mistake was discovered and corrected. A registered nurse confirmed that the incorrect insulin type was ordered and administered during this period.
Failure to Provide Adequate Social Interaction for Resident
Penalty
Summary
The facility failed to provide an environment that enhances the quality of life for Resident R37, who has a history of dementia, Type 2 Diabetes, heart failure, post-traumatic seizures, bipolar disorder, and traumatic brain injury. Despite enjoying watching TV and spending time in common areas, Resident R37 was observed multiple times sitting alone in his/her room, often yelling for help and expressing a desire for social interaction. On 3/26/24, Resident R37 was found alone in his/her room yelling for help and expressed a desire to visit the lounge, but a nurse aide indicated that the resident's yelling often disturbed others. Subsequent observations on 3/27/24 and 3/28/24 revealed that Resident R37 spent extended periods alone in his/her room without personal interactions, except for brief periods in the beauty shop, near the nurse's station, and during lunch in the lounge. On 3/29/24, the resident was again observed eating breakfast alone in his/her room with the door ajar. Interviews with the Director of Nursing and the Director of Activities confirmed that Resident R37 should not be left alone in his/her room for extended periods and should be brought out to common areas to interact with other residents and staff. The facility's failure to ensure that Resident R37 had adequate social interaction and engagement in common areas constitutes a deficiency in honoring the resident's right to a dignified existence, self-determination, and communication, as required by 28 Pa. Code 201.29 (a) and 28 Pa. Code 211.12 (d)(1)(3)(5).
Failure to Follow Safety Measures Resulting in Resident Falls
Penalty
Summary
The facility failed to ensure essential resident safety measures were followed to prevent falls for two residents. For Resident R26, the facility's policy required the use of footrests when transporting residents in wheelchairs. However, on 2/21/24, a CNA pushed Resident R26 down the hallway without the leg rests attached. As a result, the resident's feet dropped and got stuck under the wheelchair, causing the resident to be thrown to the floor and land face down. The Director of Nursing (DON) confirmed that the leg rests should have been in place to prevent such an incident, and Resident R26 expressed that the fall could have been prevented if the leg rests were used, as they made the resident feel safer. For Resident R37, the clinical record indicated that the resident required transfer assistance from two staff members using a wheeled walker. However, on 1/17/24, the resident was transferred by only one staff member, leading to the resident's knees giving out and a subsequent fall. The DON confirmed that the staff failed to follow the physician's order for a two-person transfer, which compromised the resident's safety during the transfer process.
Failure to Maintain Proper Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter. The facility's policy required that urinary drainage bags and tubing be kept off the floor at all times. However, observations revealed that the urinary drainage bag of a resident with an indwelling urinary catheter was lying flat on the floor with the drainage spout facing down and touching the floor. This was observed twice within an hour. During an interview, an LPN confirmed that the urinary drainage bag should not be on the floor and that a privacy cover should be in place. The resident had a history of urinary tract infection, hypertension, and hyperlipidemia.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 30 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oil City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oil City Nursing And Rehab | 2.7 mi | ★★★★★ | 1 | 0 |
| Upmc Northwest Transitional Care Unit | 3.1 mi | ★★★★★ | 2 | 0 |
| Caring Place, The | 7.7 mi | ★★★★★ | 1 | 0 |
| Sugar Creek Care Center | 10.4 mi | ★★★★★ | 19 | 0 |
| Titusville Nursing And Rehab | 14.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.