Inspection·December 18, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to ensure physician's orders were followed for three (Residents #27, #89, and #91) of seven residents reviewed for physician's orders. The facility census was 88.Findings include: 1. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including left foot amputation, sepsis, type II diabetes mellitus, chronic ulcer of the left foot, end stage renal disease, dialysis dependent, heart disease, and hypertension. Review of the quarterly Minimum Data set (MDS) assessment completed 11/06/25 revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating the resident was cognitively intact.Review of resident #27's medical record revealed an order dated 11/06/25 for a daily weight once a day for Resident #27.Review of Resident #27's medical record revealed no documentation of weights being obtained on 11/13/25, 11/17/25, and 11/29/25.Review of Resident #27 orders dated 11/29/25 revealed an order for insulin aspart 100 units/milliliter (ml) flex pen, inject 18 units subcutaneously before meals for type two diabetes mellitus.Review of Resident #27 orders revealed an order dated 12/10/25 for NovoLog 100 units/ml flex inject as per sliding scale: if 121-200 give 2 units; 201-250 give 4 units; 251-300 give 6 units; and 301-350 give 8 units; 351-400 give 10 units subcutaneously before meals and at bedtime for type two diabetes mellitus. If blood sugar is greater than 400 notify medical director immediately.Record review including progress notes, Medication Administration Record (MAR) and Treatment Administration Record (TAR) for November and December 2025 revealed no documented evidence that Resident #27 receiving insulin aspart on 11/15/25 and 11/28/25 and no documented evidence Resident #27 received NovoLog 11/15/25, 12/08/25, and 12/09/25. In addition, there was no documented evidence Resident #27 had a blood sugar check as ordered by the physician on 12/08/25 after 8:36 A.M. and on 12/09/25 after 5:43 P.M.2. Record review revealed Resident #89 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, dementia, gastro-esophageal reflux disease, anxiety, hyperlipidemia, and benign prostatic hyperplasiaReview of Resident #89 MDS assessment completed on 08/21/25 revealed a BIMS score of 9 of 15, indicating moderate cognitive impairment.Review of Resident #89's physician's orders revealed an order dated 09/18/25 for buspirone oral tablet 10 milligram (mg) give one tablet by mouth once daily for anxiety, and order dated 09/19/25 for amlodipine tablet 5 mg give one tablet by mouth one time a day related to hypertension, and an order dated 09/19/25 for aspirin tablet chewable 81 mg give one tablet by mouth one tine a day related to atherosclerotic heart disease of native coronary artery without angina pectoris.Review of Resident #89 October 2025 MAR revealed no documented evidence of aspirin 81 mg, amlodipine 5 mg, and Buspirone 10 mg being administered to Resident #89 on 10/04/25, 10/11/25, 10/12/25, 10/14/25, and 10/15/25.3. Review of the closed medical record revealed Resident #91 was admitted to the facility on [DATE] with diagnoses including heart disease, pancytopenia, anemia, bradycardia, hypertension, peripheral vascular disease, hyperlipidemia, anxiety, and hypokalemia,Review of Resident Residents Affected - Few (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 365147 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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)