Inspection·March 29, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm During an interview on 3/29/24, at 9:58 a.m. the Director of Nursing and Director of Activities confirmed that Resident R37 should not be left in his/her room for extended periods of time alone but brought out to common areas to interact with other residents and staff. 28 Pa. Code 201.29 (a) Resident Rights Residents Affected - Few 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395502 If continuation sheet Page 2 of 5 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 395502 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Heights Village 10 Vo Tech Drive Oil City, PA 16301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical and facility records, and resident and staff interviews, it was determined that the facility failed to ensure essential resident safety measures were followed to prevent a fall for two of 18 residents reviewed (Residents R26, R37). Findings include: Review of facility policy Wheelchair, Geriatric Chair, Broda Chair, Misc. Resident Transport Chair Safety, dated 7/24/23, indicated Foot rests must be used when staff are assisting residents who are transported by wheelchair and, Broda chair or any chair with attachable footrests to prevent accident/injury unless resident is able to self propel. Review of Resident R26's clinical record revealed an admission date of 10/04/23, with diagnoses that included calculus of ureter (a formation kidney stones in a tube that urine passes from kidneys to bladder), neutropenia (a type of white blood cell and is at a low level in the blood), cystitis (infection of bladder), and muscle weakness. Review of the Minimum Data Set (MDS-a federally mandated standardized assessment process conducted to plan resident care) assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status-a tool used to assess cognitive function) with score of 12/15, that indicated moderate cognitive impairment. Review of an initial facility incident report dated 2/21/24, revealed a staff description and statement that Registered Nurse Supervisor watched CNA (Certified Nursing Assistant) push resident down the hallway in wheelchair with no legrests on chair. Nurse saw resident's feet drop down and start to go under chair nurse yelled Stop pushing resident, he/she's going to fall out his/her chair. At this time, resident was already being thrown from wheelchair and landed on the floor - face and forehead hit the floor. The nursing progress notes dated 2/21/24, at 19:50 p.m. revealed Resident R26 was being pushed down the hallway in his/her wheelchair. Resident R26's legs dropped down. Nurse yelled to stop pushing resident that he/she was going to fall out of his/her wheelchair. Resident was thrown from his/her wheelchair and landed face down on the floor. An interview with Resident R26 on 3/26/24, at 10:15 a.m. revealed that he/she was being pushed by a staff member in his/her wheelchair without the leg rests down the hallway on 2/21/24. He/she indicated that he/she always wants the leg rests on the wheelchair, because it makes him/her feel safer. Resident R26 further indicated that his/her legs got stuck under the wheelchair, and he/she was thrown to the floor. He/she indicated the fall could of been prevented if staff placed the wheelchair leg rests on prior to pushing him/her. During an interview on 3/28/24, at 1:50 p.m. the Director of Nursing (DON) confirmed the wheelchair leg rests are always to be on a resident's wheelchair during transport. The DON confirmed that during Resident R26's transport on 2/21/24, the wheelchair leg rests were not in place which allowed the resident's legs to get lodged under the wheelchair resulting in him/her being thrown to the floor. The DON confirmed that Resident R26 should have had leg rests on his/her wheelchair to prevent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395502 If continuation sheet Page 3 of 5 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 395502 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Heights Village 10 Vo Tech Drive Oil City, PA 16301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 injury when being pushed by staff. Level of Harm - Minimal harm or potential for actual harm Review of Resident R37's clinical record revealed an original admission date of 2/23/18, with diagnoses including dementia, Type 2 Diabetes (condition of improper insulin levels that affects how the body uses blood sugar), heart failure, post traumatic seizures, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and traumatic brain injury. Residents Affected - Few Review of a physician's order dated 1/09/24, revealed that Resident R37 was to be transferred with the assistance of two staff while utilizing a wheeled walker. A facility investigation dated 1/17/24, indicated that Resident R37 was being transferred to a chair with the assistance of one staff member, and during the transfer his/her knees gave out and he/she fell to his/her knees. During an interview on 3/28/24, at 2:12 p.m. the DON confirmed Resident R37 should have had the assistance of two staff members and utilize a wheeled walker to transfer and that on 1/17/24, staff failed to transfer Resident R37 in a safe manner. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12 (d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395502 If continuation sheet Page 4 of 5 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 395502 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Heights Village 10 Vo Tech Drive Oil City, PA 16301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on review of facility policy and clinical records, observations and staff interview, it was determined that the facility failed to provide appropriate care regarding a urinary catheter (a tube placed and held in the bladder to drain urine) for one of 18 residents reviewed (Resident R62). Findings include: Review of facility policy entitled Emptying a Urinary Drainage Bag (a bag that holds urine that comes from a tube placed and held in the bladder to drain urine), dated 7/24/23, indicated to keep the drainage bag and tubing off the floor at all times . Review of Resident R62's clinical record revealed an admission date of 12/17/23, with diagnoses that included urinary tract infection (an infection in any part of the urinary system), hypertension (high blood pressure), and hyperlipidemia (high cholesterol). Review of Resident R62's Quarterly Minimum Data Set (MDS-a mandated assessment of a residents abilities and care needs) assessment, dated 2/1/24, revealed that Resident R62 had an indwelling urinary catheter. Observation on 3/27/24, at 8:50 a.m. revealed Resident R62's urinary drainage bag lying flat on the floor with no covering in place and the drainage spout (the part of the urinary bag that opens to empty urine from the bag) facing down and touching the floor. Observation on 3/27/24, at 9:55 a.m. revealed Resident R62's urinary drainage bag remained lying flat on the floor with no covering in place and the drainage spout facing down and touching the floor. During an interview on 3/27/24, at 9:55 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that the urinary drainage bag should not be on the floor. He/she also confirmed that there should be a privacy cover on the urinary drainage bag. 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395502 If continuation sheet Page 5 of 5