Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oil City Nursing And Rehab during CMS and state inspections, most recent first.
A resident with syncope, ESRD, and dependence on dialysis was sent to the hospital from dialysis after a decline in health status, but the clinical record did not document the resident’s status after the transfer. The MDS indicated discharged return anticipated, and the DON confirmed the record lacked evidence of what happened after the resident was sent to the ER.
A facility failed to update a resident's care plan to reflect the discontinuation of dialysis services. Despite a physician's order for the removal of the dialysis catheter and multiple MDS assessments indicating the resident was not receiving dialysis, the care plan continued to include interventions related to dialysis. This oversight was confirmed by the RN Assessment Coordinator.
The facility did not properly store Schedule II-V medications as required by their policy. In the Unit A, C, and D medication room, a locked compartment containing injectable Lorazepam was found to be affixed to a rack that was not permanently attached to the refrigerator. This was confirmed by the Assistant DON, highlighting a failure to comply with the facility's medication storage policy.
The facility failed to document fluid intake and urinary output as per physician's orders for two residents with foley catheters. The facility's policy required documentation of urinary drainage and fluid intake, but records for both residents showed multiple instances of missing documentation. The Director of Nursing confirmed the lack of required documentation.
A resident with a fractured hip, pressure ulcer, and cognitive impairment sustained an ankle fracture during a transfer. The care plan required extensive assistance for transfers, including the use of a mechanical lift with two staff members. However, the resident was transferred using a sit-to-stand lift with only one staff member, leading to the injury. Inconsistent staff statements and gaps in documentation hindered the investigation. The absence of a physician's order for the sit-to-stand lift and incomplete investigation were contributing factors.
A resident with cognitive impairment and extensive transfer needs sustained an acute bimalleolar fracture of the left ankle. The facility's investigation was incomplete, lacking statements from all relevant staff and containing inconsistent accounts of the incident.
Incomplete record after hospital transfer from dialysis
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, who was admitted with diagnoses including syncope and collapse, end stage renal disease, and dependence on dialysis. The resident’s record showed that on 2/27/26 the resident was at dialysis, could not receive dialysis because of a decline in health status, and was sent to the hospital. However, as of 3/27/26, the clinical record still lacked evidence of the resident’s status after being sent to the emergency room from dialysis, even though the MDS dated 2/27/26 indicated discharged return anticipated. During interview, the DON confirmed that the record did not reflect the resident’s status after transfer to the hospital while at dialysis.
Failure to Update Care Plan for Resident No Longer Requiring Dialysis
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident, identified as Resident R60, to reflect the current necessary care and services. Resident R60 was admitted with diagnoses including long-term kidney disease, sudden kidney failure, and high blood pressure. A physician's order dated June 18, 2024, indicated the removal of the resident's dialysis catheter as the resident no longer required dialysis treatment. However, the care plan, initiated on June 5, 2024, continued to include interventions related to dialysis, such as transportation to dialysis sessions and coordination with the dialysis treatment facility. Despite the resident's change in condition, the care plan was not updated to reflect the discontinuation of dialysis services. This oversight was confirmed during an interview with the Registered Nurse Assessment Coordinator, who acknowledged that the care plan lacked evidence of being updated. The facility's policy requires that care plans be revised as the resident's condition changes and reviewed at least quarterly, in conjunction with the Minimum Data Set (MDS) assessments. However, multiple MDS assessments indicated that the resident was not receiving dialysis services, yet the care plan remained unchanged.
Improper Storage of Controlled Substances
Penalty
Summary
The facility failed to store Schedule II-V medications in compliance with their policy, which requires these controlled substances to be stored in a permanently affixed, double-locked compartment separate from other medications. During an observation of the Unit A, C, and D medication room, it was found that the refrigerator contained a locked compartment with two boxes of injectable Lorazepam, a controlled substance. However, the compartment was only affixed to a rack that was not permanently attached to the refrigerator. This was confirmed by the Assistant Director of Nursing during an interview, indicating a failure to adhere to the facility's medication storage policy.
Failure to Document Fluid Intake and Urinary Output
Penalty
Summary
The facility failed to document fluid intake and urinary output as per physician's orders for two residents with foley catheters. The facility's policy required the urinary drainage bag to be emptied every eight hours and the amount of urine to be documented, as well as the amount of liquids consumed to be recorded in the resident's medical record. However, for Resident R49, the Treatment Administration Record (TAR) and Tasks Record showed multiple instances where fluid intake and urinary output were not documented every shift as ordered by the physician. Similarly, Resident R83's records also lacked documentation of fluid intake and urinary output every shift as per physician's orders. The Director of Nursing confirmed that the clinical records for Residents R49 and R83 did not have the required documentation for fluid intake and urinary output on the specified dates. This deficiency was identified during a review of facility policies, clinical records, and staff interviews, indicating a failure to adhere to the physician's orders and facility policies regarding the documentation of fluid intake and urinary output for residents with foley catheters.
Inadequate Safety Measures Result in Resident Injury
Penalty
Summary
The facility failed to implement appropriate safety measures to protect Resident R15 from injury, resulting in an ankle fracture that required hospital treatment. Resident R15, admitted with a fractured left hip, pressure ulcer, and cognitive impairment, had a care plan requiring extensive assistance for transfers. Despite the policy requiring two staff members for safe mechanical lift transfers, Resident R15 was transferred using a sit-to-stand lift with only one staff member present, leading to the injury. Multiple staff members provided inconsistent statements regarding the events leading to Resident R15's injury. The investigation revealed gaps in documentation and witness statements, indicating a lack of clarity on how the ankle fracture occurred. The facility's failure to conduct a thorough investigation and the absence of a physician's order for the sit-to-stand lift were highlighted as contributing factors to the deficiency. The Nursing Home Administrator acknowledged the incomplete investigation and inconsistent statements surrounding Resident R15's injury. The deficiency was cited under regulatory codes related to management, resident care policies, nursing services, and licensee responsibility. The facility's failure to ensure adequate supervision and implement necessary safety measures resulted in actual harm to Resident R15, highlighting a critical lapse in ensuring resident safety and preventing accidents.
Incomplete Investigation of Resident Injury
Penalty
Summary
The facility failed to fully investigate an incident involving a resident (R15) who sustained an injury of unknown origin. The resident, who was cognitively impaired and required extensive assistance for transfers, was found to have increased pain, bruising, and swelling in the left lower extremity. An x-ray revealed an acute bimalleolar fracture deformity of the left ankle. Despite the severity of the injury, the facility's investigation was incomplete and lacked statements from all staff who had contact with the resident during the relevant timeframe. The investigation also contained inconsistent statements that were not further explored. The incident report and clinical records indicated that the resident's injury was not observed by any staff, and the resident was unable to explain how it occurred. Witness statements from various staff members provided conflicting accounts of the care provided to the resident, including the use of a sit-to-stand lift with varying levels of assistance. The Nursing Home Administrator confirmed that the investigation was insufficient and should have included more thorough documentation and additional staff witness statements.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oil City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakwood Heights Village | 2.7 mi | ★★★★★ | 19 | 0 |
| Upmc Northwest Transitional Care Unit | 5.8 mi | ★★★★★ | 2 | 0 |
| Caring Place, The | 9.4 mi | ★★★★★ | 1 | 0 |
| Sugar Creek Care Center | 11.8 mi | ★★★★★ | 19 | 0 |
| Titusville Nursing And Rehab | 12.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.