Oakwood Heights Village
Inspection Findings
F-Tag F0600
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 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 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 Resident R1's bed and his/her roommates' bed and when agency Employee E1 went to roll Resident Resident R1 towards him/her he/she did not realize how stiff Resident Resident R1 was and Resident 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 Resident R1 his/her head hit the other bed because it was so close, and nobody told him/her that Resident Resident R1 was so stiff. Resident 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 Resident R1's room. He/she went to Resident Resident R1's room to see what was going on. The agency CNA Employee E1 was sitting on Resident Resident R1's bed facing the windows with Resident Resident R1 laying across his/her lap. Resident 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 Resident R1 fell out of bed.
Employee E4 then left the room to call the RN and when he/she returned Resident Resident R1 was completely in bed bleeding from his/her forehead. The facility investigation revealed that Resident 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 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 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 Resident R1 required two staff for bed mobility/rolling side to side and attempted to roll Resident Resident R1 independently causing harm to Resident 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
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Printed: 04/13/2026 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
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-Tag F0689
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
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OAKWOOD HEIGHTS VILLAGE in OIL CITY, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in OIL CITY, PA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from OAKWOOD HEIGHTS VILLAGE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.