Health inspection·October 22, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete see detailed pictures of organs, bones, and body tissues) done of his/her head and that it showed a small hemorrhage. Physicians Assistant stated that normally they would send resident to larger hospital for observation and consult with neurosurgery, but due to CMO (Comfort Measures Only) status residents family does not want him/her sent and that resident would be sent back to facility for us to monitor and keep comfortable as needed. RN phoned and updated on phone call. Resident R1's clinical record revealed CT scan results dated 8/5/25, at 1:50 p.m. indicating acute (new) very low volume bilateral intraventricular hemorrhage. The facility investigation revealed RN Employee E2 emailed the Director of Nursing (DON) a statement on 8/6/25 at 9:30 a.m. indicating he/she was called to the third floor for a resident who had fallen. Once he/she arrived in the room Resident R1 was laying supine in his/her bed with a significant laceration on his/her right forehead. RN Employee E2 asked agency CNA Employee E1 what had happened. Agency CNA Employee E1 stated that he/she was standing between Resident R1's bed and his/her roommates' bed and when agency Employee E1 went to roll Resident R1 towards him/her he/she did not realize how stiff Resident R1 was and Resident R1's torso rolled out of the bed and struck his/her forehead on the bed frame of the roommates' bed. Agency Employee E1 was asked to wait at the nurse's station at that time, and he/she was relieved of his/her duties and left the building. The facility investigation revealed that agency CNA Employee E1 provided a written statement with an incident date of 8/5/25, which revealed, that as he/she was turning Resident R1 his/her head hit the other bed because it was so close, and nobody told him/her that Resident R1 was so stiff. Resident R1 hit his/her head on the edge of the bed and agency Employee E1 called for help. The facility investigation revealed that CNA Employee E4 provided a written statement with an incident date of 8/5/25, indicating he/she was assisting another Resident when he/she heard several bangs coming from Resident R1's room. He/she went to Resident R1's room to see what was going on. The agency CNA Employee E1 was sitting on Resident R1's bed facing the windows with Resident R1 laying across his/her lap. Resident R1's upper half was laying on the bed, his/her mid-section was on the agency CNA Employee E1's lap, and his/her legs were out of the bed towards the roommate's bed. Upon his/her arrival the agency CNA Employee E1 indicated that Resident R1 fell out of bed. Employee E4 then left the room to call the RN and when he/she returned Resident R1 was completely in bed bleeding from his/her forehead. The facility investigation revealed that Resident R1 is non-verbal and could not provide a statement or any details related to the incident. A review of employment documents revealed that agency CNA Employee E1 signed the nursing agency's orientation policy related abuse and neglect to ensure safe care of all residents on 9/7/24. Documentation submitted by the facility, dated 8/5/25, revealed that the facility initiated an investigation and the agency CNA Employee E1 was asked to leave the facility immediately and would not be returning. During interviews on 10/21/25, with RN Employees E2 and E9, LPN Employees E3, E5, and E6, and CNA Employees E7 and E8, all confirmed that Resident R1 was always an assist of two for transfers/bed mobility rolling side to side and the information could be found under the task orders. The facility failed to ensure that Resident R1 was free from neglect resulting in actual harm of a laceration to the right forehead and an intraventricular hemorrhage. During an interview on 10/21/25, at approximately 9:30 a.m. the DON confirmed that the agency CNA Employee E1 did not ask for assistance, did not follow the task orders, and did not follow the care plan which indicated Resident R1 required two staff for bed mobility/rolling side to side and attempted to roll Resident R1 independently causing harm to Resident R1. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 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 10/22/2025 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on review of facility policy, facility documentation, and clinical records, and staff interviews, it was determined that the facility failed to provide the required level of assistance with bed mobility (rolling side to side or turning in bed) as identified in the plan of care, task order summary, and in accordance with facility policy which resulted in actual harm of a laceration to the right forehead and an intraventricular hemorrhage (brain bleed) for one of 11 residents reviewed (Resident R1). This deficiency is cited as past non-compliance. Findings include: The Safe Resident Handling/Transfers policy, dated 1/14/25, revealed, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident . Resident R1's clinical record revealed an admission date of 8/18/19, with diagnoses that included Alzheimer's Disease (a progressive disorder that affects memory, thinking, and behavior), Parkinsonism (movement disorder which includes slowness of movement, muscle stiffness, and tremors), and muscle weakness. Resident R1's task order summary (a program used by nursing staff to verify resident bed mobility assist orders) revealed task order reviews dated 10/25/23, 1/16/24, and 7/30/25, all indicating to utilize an assist of two staff for rolling side to side. Resident R1's ADL (Activities of Daily Living) Self Care Performance Deficit care plan, date initiated 11/12/23, revealed, Bed Mobility: The resident is totally dependent on two staff for repositioning and turning in bed. Resident R1's clinical record revealed a nursing note written by Registered Nurse (RN) Employee E2, dated 8/5/25, at 5:56 a.m. CNA (Certified Nursing Assistant) was performing AM care with resident. When resident was rolled, he/she rolled out of bed and struck his/her head on the roommate's bed frame. Resident was assessed. 3 cm (centimeter) x 0.6 cm laceration to right forehead with bruising observed. Wound was cleansed with normal saline, steri-strips (thin adhesive bandages used to close small shallow wounds by sealing the edges of the wound together) were applied with good approximation of skin. Bleeding was controlled. Neuro-checks (assessments completed to check overall brain function) initiated per facility protocol. PCP (Primary Care Provider) and family updated.Resident R1's clinical record revealed a nursing note written by RN Employee E10, dated 8/5/25, at 10:16 a.m. that identified Resident continues to be in a great deal of pain following his/her fall and the injury to his/her forehead. Resident continues to cry in pain. Tylenol administered per order. After assessment of the open area this resident MD (Medical Doctor) contacted, and order received to transfer to hospital for eval and treatment with possible stitches. Residents HOB (head of bed) placed at 30 degrees. Neuro checks continue and are WNL (within normal limits). Family notified. Will continue to monitor.Resident R1's clinical record revealed a nursing note written by Licensed Practical Nurse (LPN) Employee E3, dated 8/5/25, at 2:38 p.m. that included call received from the local hospital's Emergency Department PA-C (Certified Physicians Assistant) stating that resident had a CT scan (Computed Tomography Scan- an imaging test used to see detailed pictures of organs, bones, and body tissues) done of his/her head and that it showed a small hemorrhage. Physicians Assistant stated that normally they would send resident to larger hospital for observation and consult with neurosurgery, but due to CMO (Comfort Measures Only) status residents family does not want him/her sent and that resident would be sent back to facility for us to monitor and keep comfortable as needed. RN phoned and updated on phone call. Resident R1's clinical record revealed CT scan results dated 8/5/25, at 1:50 p.m. indicating acute (new) very low volume bilateral intraventricular hemorrhage. The facility investigation revealed RN Employee E2 emailed the Director of Nursing (DON) a statement on 8/6/25 at 9:30 a.m. indicating he/she was called to the third floor for a resident who had fallen. Once he/she arrived in the room Resident R1 (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 10/22/2025 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 - Actual harm Residents Affected - Few was laying supine in his/her bed with a significant laceration on his/her right forehead. RN Employee E2 asked agency CNA Employee E1 what had happened. Agency CNA Employee E1 stated that he/she was standing between Resident R1's bed and his/her roommates' bed and when agency Employee E1 went to roll Resident R1 towards him/her he/she did not realize how stiff Resident R1 was and Resident R1's torso rolled out of the bed and struck his/her forehead on the bed frame of the roommates' bed. Agency Employee E1 was asked to wait at the nurse's station at that time, and he/she was relieved of his/her duties and left the building. The facility investigation revealed that agency CNA Employee E1 provided a written statement with an incident date of 8/5/25, which revealed, As he/she was turning Resident R1 his/her head hit the other bed because it was so close, and nobody told him/her that Resident R1 was so stiff. Resident R1 hit his/her head on the edge of the bed and agency CNA Employee E1 called for help. The facility investigation revealed that CNA Employee E4 provided a written statement with an incident date of 8/5/25, indicating he/she was assisting another Resident when he/she heard several bangs coming from Resident R1's room. He/she went to Resident R1's room to see what was going on. The agency CNA Employee E1 was sitting on Resident R1's bed facing the windows with Resident R1 laying across his/her lap. Resident R1's upper half was laying on the bed, his/her mid-section was on the agency CNA Employee E1's lap, and his/her legs were out of the bed towards the roommate's bed. Upon his/her arrival the agency CNA Employee E1 indicated that Resident R1 fell out of bed. Employee E4 then left the room to call the RN and when he/she returned Resident R1 was completely in bed bleeding from his/her forehead. The facility investigation revealed that Resident R1 was non-verbal and could not provide a statement or any details related to the incident. Documentation submitted by the facility, dated 8/5/25, revealed that the facility initiated an investigation and the agency CNA Employee E1 was asked to leave the facility immediately and would not be returning. During interviews on 10/21/25, with RN Employees E2 and E9, LPN Employees E3, E5, and E6, and CNA Employees E7 and E8, all confirmed that Resident R1 was always and assist of two for transfers/bed mobility rolling side to side and the information could be found under the task orders. During an interview on 10/21/25, at approximately 9:30 a.m. the DON confirmed that the agency CNA Employee E1 had attempted to roll Resident R1 independently and did not follow the task orders and care plan which indicate Resident R1 required two for bed mobility rolling side to side. The facility failed to ensure that Resident R1 was provided adequate assistance in accordance with their task orders and care plan to utilize two staff for bed mobility rolling side to side, causing a laceration to the right forehead and an intraventricular hemorrhage. This deficiency is cited as past non-compliance. On 8/6/25, the facility-initiated education for all nursing staff including RN's, LPN's, and CNA's to ensure that resident transfers and bed mobility care are performed per resident care plans and facility task orders. This plan included the following: Immediate Suspension and Do Not Return of agency CNA Employee E1 Immediate education regarding checking transfer status/ bed mobility before providing care was provided to nursing staff which included RN's, LPN's, and CNA's, which occurred from 8/6/25, through 8/7/25. Review of all resident transfer/bed mobility statuses completed by the DON on 8/6/25. All staff included in the education also completed competencies conducted by the Management Team. Interviews with RN Employees E2 and E9, LPN Employees E3, E5, and E6, and CNA Employees E7 and E8, confirmed the facility-initiated education and competencies starting 8/6/25, which included education on checking transfer status/ bed mobility before providing resident care and performing a return demonstration to ensure proper knowledge and technique. Audits were conducted to ensure residents are transferred per their care plans and task orders, which occurred on all shifts and on all units from 8/11/25, through 10/10/25 with all transfers/bed mobility rolling side to side performed appropriately. The (continued on next page) 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 10/22/2025 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete facility has demonstrated compliance with using correct transfer/bed mobility status for residents since 9/8/25. During an interview with the NHA and the DON on 10/22/25, at approximately 2:30 p.m. and review of the facility's immediate actions, education, competencies, and audits, it was verified that the facility had implemented a plan of correction to ensure residents are free from harm/injury regarding transfer status/bed mobility rolling side to side of residents and had achieved substantial compliance. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Event ID: Facility ID: 395502 If continuation sheet Page 5 of 5