Health inspection·December 4, 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 Based on review of clinical records and facility policy, and staff interviews, it was determined that the facility failed to accurately transcribe a physician's order to promote comfort during care and/or prevent discomfort for one of three residents reviewed (Resident R1). Findings include: Review of facility policy entitled Medication Orders dated 1/14/25, revealed PRN Medication Orders - When recording PRN medication orders, specify. the reason for administration. Review of facility policy entitled Medication and Treatment Orders dated 1/14/25, revealed Orders for medications must include. symptoms for which the medication is prescribed. Review of Resident R1's clinical record revealed an admission date of 5/28/21, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), dementia (a disease that affects short term memory and the ability to think logically)and hypertension (high blood pressure). Review of hospice physician's order dated 10/12/25, revealed an order to pre-medicate (premed) prior to care with Ativan (anti-anxiety medication) 0.5 mg (milligrams) every 2 hours as needed (PRN) and morphine 10 milligrams (mg) every two hours PRN. Review of facility transcribed physician orders revealed an order dated 10/12/25, transcribed at 2:30 p.m. for Lorazepam (Ativan) 0.5 mg every two hours PRN for premed prior to care. Another order dated 10/10/25, for Morphine 20 mg/ml (milliliter) give 0.5 ml every hour PRN and lacked instructions to premed prior to care as ordered on 10/12/25. Further review revealed a physician's order dated 10/12/25, to reposition Resident R1 every two hours. Review of Resident R1's Medication Administration Record r(MAR) revealed that on 10/12/25, PRN Ativan and PRN Morphine were administered at 4:38 p.m. and no other administration documented after that administration. On 10/13/25, PRN Morphine was administered at 1:53 a.m., 5:30 a.m., 1:15 p.m., 4:54 p.m., 5:22 p.m., then again on 10/14/25, at 9:15 a.m., 11:21 a.m., 2:00 p.m., 3:58 p.m., and 8:00 p.m., then again on 10/15/25 at 12:07 a.m., 4:18 a.m., 11:31 a.m., 2:07 p.m., 6:16 p.m.; the PRN Lorazepam was not administered with PRN morphine as ordered. Further review of Resident R1's MAR revealed that Resident R1 was repositioned on 10/12/25, at 6:00 p.m., 8:00 p.m., and 10:00 p.m., then again on 10/13/25, at 12:00 a.m., 2:00 a.m., 4:00 a.m., 6:00 a.m., 8:00 a.m., 10:00 a.m., and 12:00 p.m There was no evidence that Resident R1 was premedicated with his/her PRN Lorazepam and PRN Morphine prior to his/her care as ordered. Review of Resident R1's task (charting area where nursing assistants document in the clinical record) revealed that Resident R1 was repositioned on 10/13/25, at 10:00 p.m., then again on 10/14/25, at 12:00 a.m., 4:00 a.m., 6:00 a.m., 10:00 a.m., and 12:00 p.m., There was no evidence that Resident R1 was premedicated with his/her PRN Lorazepam and PRN Morphine prior to his/her care as ordered. Review of Resident R1's nursing progress notes revealed a note dated 10/12/25, at 11:23 p.m., indicating that Resident R1 appears comfortable other than when care is provided. Another nursing progress noted dated 10/13/25, at 5:02 p.m. indicated that Resident R1 had increased moaning and anxiety while repositioning and incontinence care being provided. During an interview on 12/3/25, at 9:55 a.m. the Director of Nursing confirmed that Resident R1's Morphine order lacked instructions to 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 3 Event ID: 395502 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 12/04/2025 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)