Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to two complaints completed on August 21, 2019, it was determined that Oil City Healthcare and Rehabilitation Center was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

 Plan of Correction:

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.

Based on observations and staff interview, it was determined that the facility failed to provide a clean sanitary bathing area in two of four shower areas (women's and B Wing showers).

Findings include:

Observations of the facility shower areas on 8/20/19, between 3:00 p.m. and 3:30 p.m. revealed the following:

A bedside commode bucket on the floor of the shower stall in the women's shower room contained fecal matter and urine and two bedside commodes with brown substance and stains on the seats.

A shower stall on the B Wing contained two bedside commode buckets on the shower stall floor.

During an interview on 8/20/19, at 3:25 p.m. the Assistant Director of Nursing confirmed the above findings in the women's and B Wing showers.

28 Pa. Code 201.18 (b)(1)(3) Management

 Plan of Correction - To be completed: 10/01/2019

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.

The shower room bucket and bedside commodes were cleaned/disinfected and those that are no longer needed for use were removed and put in storage.

All shower rooms/bathing areas equipment will be cleaned by nursing staff/CNA after each use on a continuing basis. Nursing staff will follow the cleaning schedule as assigned for these areas.

Nursing staff will be in-serviced by the Director of Clinical Education on the cleaning schedule for bathing areas and cleaning equipment in shower/bathing area after each use.

The Nursing Supervisors or designee will audit cleaning schedules and check shower rooms/bathing areas prior to end of each shift to ensure no visible debris were left on equipment and that items are up off the floor for one week, then twice a week for two weeks, and finally once a month for a month. The results will be reported to the Quality Assessment and Process Improvement Committee for two months.

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