Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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.
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 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.
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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.
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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 | — | 0 | 0 |
| Caring Place, The | 7.7 mi | — | 1 | 0 |
| Sugar Creek Care Center | 10.4 mi | — | 7 | 0 |
| Titusville Nursing And Rehab | 14.7 mi | — | 0 | 0 |
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