Oil City Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Oil City Nursing and Rehab, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 5, 2024

  Based on review of facility policy, clinical records, and facility documentation, and staff interviews, it was determined that the facility failed to implement appropriate safety measures in a manner that protected a resident from injury of unknown origin and resulted in actual harm when the resident received an ankle fracture that required medical treatment at a hospital for one of 18 residents reviewed (Resident R15). Findings include: Review of a facility policy entitled Investigating Injuries dated 2/20/24, revealed that an Injury of unknown source is defined as an injury that meets both of the following conditions: a. The source of the injury was not observed by any person or the injury could not be explained by the resident; and b. […]

• No harm, potential for more than minimal, patternF553Jul 15, 2021

  Based on review of facility policy and staff and resident interviews, it was determined that the facility failed to include the resident in the care plan interdisciplinary meetings for three of 18 residents (Residents R2, R51 and R54). Findings include: The Resident Care Plan Conference Process policy, dated 1/19/21, revealed that (3) Social Service personnel or designee will document in the resident's medical record that the invitation to attend has been provided to the resident and/or resident representative and (4) the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person centered care plan for each resident and (5) the resident will be informed of his or her right to participate in his… […]

• No harm, potential for more than minimal, patternF655Jul 15, 2021

  Based on review of clinical records and staff interview, it was determined that the facility failed to ensure that baseline care plans were reviewed with residents and/or their representative and that a copy of the baseline care plan was provided to the resident and/or the resident's representative for five of 18 residents reviewed (Residents R59, R9, R28, R32, and R54). Findings include: Resident R32's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record included a care plan, developed upon admission, but lacked evidence/documentation that the baseline care plan was reviewed with the resident and/or the resident representative or that a copy was provided. […]

• No harm, potential for more than minimal, patternF657Jul 15, 2021

  Based on review of clinical records and facility policies and staff and resident family interviews, it was determined that the facility failed to show evidence of having Resident Care Plan Conference meetings and also failed to have the required Interdisciplinary Team (IDT), members in attendance for five of 18 residents (Resident R2, R11, R29, R51 and R54). Findings include: The Resident Care Plan Conference Process policy, dated 1/19/21, revealed that (3) Social Service personnel or designee will document in the residents medical record that the invitation to attend has been provided to the resident and/or resident representative and(4) the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive,… […]

• No harm, potential for more than minimal, patternF804Jul 15, 2021

  Based on observations, review of facility policy, and staff and resident interviews, it was determined that the facility failed to provide meals that were palatable and at an appetizing temperature for three of 18 residents reviewed (Residents R16, R37 and R51). Findings include: The Food And Nutrition Services policy, dated 1/19/21, revealed food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and is served at a safe and appetizing temperature. Review of Resident Council Minutes from April 2021 revealed residents attending the council meeting complained of mushy vegetables. During an interview on 7/12/21, at 1:14 p.m., Resident R16 stated that the food has gotten worse. […]