Oakwood Heights Village

In the surveyor’s words

From the most serious findings on record at Oakwood Heights Village, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Jan 13, 2021

  Based on review of observations, facility policies and documentation, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to follow infection control guidelines from the Centers for Disease Control and Prevention (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic. This failure placed the facility in an Immediate Jeopardy situation for six of six residents reviewed (Residents R2, R4, R6, R9, R10, and R11). […]

• Actual harm, isolatedF600Oct 22, 2025

  Based on review of facility policy, facility documentation, and clinical records, and staff interviews, it was determined that the facility failed to ensure that one resident was free of neglect during care 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).Findings include: The Abuse, Neglect, and Exploitation policy, dated 1/14/25, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . […]

• Actual harm, isolatedF689Oct 22, 2025

  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. […]

• Actual harm, isolatedF689Feb 26, 2025

  Based on review of facility policy, investigation documents, and clinical records, and staff interviews, it was determined that the facility failed to maintain a safe environment regarding mechanical lift sling sizing for one of three residents that utilize a mechanical lift reviewed (Resident R46), that resulted in actual harm and required staple repair for a head laceration. Findings include: The facility's policy Safe Resident Handling/Transfers, dated 1/14/25, indicated that residents are to be transferred safely to prevent or minimize risks for injury. […]

• Actual harm, isolatedF600Dec 19, 2022

  Based on review of facility policy and documentation and clinical record, and staff interviews, it was determined that the facility failed to ensure that one of five residents reviewed (Resident R1) was free of neglect during care which resulted in actual harm of a fracture of the right clavicle (collar bone). Findings include: Review of a facility policy entitled, Skilled Nursing-Abuse last reviewed 5/11/22, indicated that each resident will be free from all forms of abuse, neglect, exploitation and misappropriation of resident property, and that the community (facility) will educate staff in techniques to protect all parties, and indicated that the facility defined neglect as the failure to provide services to a resident that are necessary to avoid physical harm, pain, mental anguish, or… […]