O'Berry Neuro-Medical Treatment Center

Inspectors wroteBased on observation, record review, and interviews with staff the facility failed to ensure a resident, whose care plan noted she should be allowed to sit on the floor if the resident chose to do so, was treated with dignity when a Nurse Aide lifted the resisting resident to her feet and dragged her to her room. This was for 1 (Resident # 1) of 3 residents reviewed for staff treatment.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to provide a safe transfer and failed to provide supervision to a resident, left unattended on the commode for 2 of 5 residents reviewed for accidents (Residents #114 and #85).

Inspectors wroteBased on record review, and staff and physician interviews, the facility failed to consult with the physician immediately when Resident #2, who had a tracheostomy, experienced a medical emergency. On 1/16/25, Resident #2 exhibited signs of pain, and her oxygen saturation levels were at 69% on room air (normal range is 95%-100%). Nurse #1 was able to stabilize the resident's oxygen saturation through administration of oxygen and she medicated the resident for pain. Later in the shift, Nurse #1 was notified by Nurse Aide (NA) #1 Resident #2's oxygen saturation levels had dropped to 55% (a life threatening level), the resident was crying, and her tongue was blue. Emergency Medical Services (EMS) and the physician were not notified immediately. [...]

Inspectors wroteBased on record review and interviews with staff and physician, the facility failed to provide nursing assessments and monitoring for Resident #2 following an acute change of condition. On 1/16/25 at approximately 3:30 AM, Resident #2 exhibited signs of pain and her oxygen saturation levels were at 69% (normal range is 95%-100%). Supplemental oxygen was applied, the physician ordered morphine 2 milligrams (mg) subcutaneously (under the skin), and instructed Nurse #1 to monitor the resident closely. Nurse #1 inadvertently administered 20 mg of morphine to Resident #2 at approximately 3:45 AM rather than the 2mg ordered by the physician. Nurse #1 nor any other nurse monitored or assessed on Resident #2 until approximately 4:40 AM when Nurse #1 was notified by Nurse Aide (NA) #1 that Resident #2's oxygen saturation levels dropped to 55%, she was crying, and her tongue was blue. [...]

Inspectors wroteBased on record review and interviews with staff and the physician, the facility failed to prevent a significant medication error when Nurse #1 administered ten times the ordered amount of morphine (narcotic pain medication) to Resident #2. On 1/16/25, Resident #2 exhibited signs of pain and her oxygen saturation levels were at 69% (normal range is 95%-100%). Supplemental oxygen was applied and the physician ordered morphine 2 milligrams (mg) subcutaneously (under the skin). Nurse #1 obtained two vials of morphine and administered them to Resident #2. She believed each vial contained 1 mg of morphine rather than the actual content of 10 mg per vial resulting in the resident receiving 20 mg instead of the physician ordered 2 mg. Approximately one hour later the resident's tongue appeared blue and her oxygen saturation level dropped to 55% on 4 liters per minute of supplemental oxygen. [...]

Inspectors wroteBased on record reviews and staff interviews, the facility failed to have a complete and accurate medication administration record for 1 of 3 residents reviewed for medical record accuracy (Resident #2).

Inspectors wroteBased on record review, and staff and Medical Director interviews, the facility failed to notify the primary care physician when Resident #103 was not provided bolus tube feedings (a way to send formula through a tube directly into the stomach) per the physician order. On 9/28/24 Nurse #1 did not feed Resident #103 his bolus tube feeding because she believed he was full. Nurse #1 was aware of the physician's orders, she deliberately disregarded them, and she independently made the decision to deviate from the physician's orders without notifying the physician. Nurse #1 confirmed this was not a new practice for her and she had done this previously for an undetermined number of times and instances without notifying the physician. [...]

Inspectors wroteBased on record review, and staff and Medical Director interviews, the facility failed to protect the residents' right to be free from neglect when Nurse #1 did not provide the necessary care and services as assessed and ordered by the physician to Resident #103. On 9/28/24 Nurse #1 did not provide Resident #103 his bolus tube feeding (a way to send formula through a tube directly into the stomach) because she thought he was full. Nurse #1 was aware of the physician's orders, she deliberately disregarded them, and she independently made the decision to deviate from the physician's orders and deprive the resident of his assessed nutritional needs. Nurse #1 revealed this was not a new practice for her and she had done this previously for the resident an undetermined number of times. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to document written advance directive information and/or an opportunity to formulate an advance directive was provided for 16 of 19 residents reviewed for advance directives. (Resident's #'s 19, 30, 40, 42, 48, 59, 63, 71, 72, 73, 83, 87, 88, 97, 99 and 125).

Inspectors wroteBased on record review and staff interviews, the facility failed to document on residents' controlled medication records that two different nurses ensured accurate reconciliation and accounting of controlled medications for 1 of 1 medication cart reviewed for controlled medication records (Cluster 1 Hall 2 medication cart).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for the use of anticoagulants (medications that increased the time it takes for blood to clot) for 1 of 31 residents whose MDS assessments were reviewed (Resident #63).

Inspectors wroteBased on record review and staff interviews, the facility failed to develop a comprehensive care plan in the area of the use of blood thinner and/or anticoagulants (a medication that increases the time it takes for blood to clot) (Resident #63) and in the area for seizures and the use of antiepileptic medications (Resident #101) for 2 of 31 residents whose comprehensive care plan was reviewed.

Inspectors wroteBased on record review, and staff, and Registered Dietician (RD) interviews, the facility failed to administer tube feedings via a gastrostomy tube (a tube to provide formula directly to the stomach) as ordered by the physician for 1 of 7 residents reviewed with tube feeding orders (Resident #103).

Inspectors wroteBased on record review, observation and staff interviews, the facility failed to secure medications in an unlocked medication room and unlocked medication cart (Building 1 Hall 4 medication room and medication cart), failed to dispose of an expired medication (Building 2 Hall 2 medication cart), failed to maintain a temperature range of 36 to 46 degrees Fahrenheit (F) for refrigerated medications and monitor the internal temperature of medication refrigerators (Building 2 Hall 2 and Building 4 Hall 3 medication rooms) for 3 of 6 medication rooms and medication carts reviewed for medication storage.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to have a complete and accurate medication and treatment administration record for 1 of 7 residents reviewed for medical record accuracy (Resident #103).

Inspectors wroteBased on record review and staff interviews, the facility failed to complete and/or record accurate nurse staffing information of hours worked for licensed and unlicensed nursing staff on the census daily staffing form for 3 of 3 resident buildings whose census daily staffing forms were reviewed (Building 1, Building 2, and Building 4).

Inspectors wroteBased on record reviews and staff and legal guardian interviews, the facility failed to manage a resident trust fund account by not crediting interest earned on resident trust accounts with a balance over $100 for 1 of 1 resident reviewed for personal funds (Resident #103).

Inspectors wroteBased on record review, Resident's Representative interview, and staff interviews, the facility failed to maintain documentation of grievances by failing to: (1) document the steps taken to investigate a grievance expressed on behalf of the resident, (2) document the findings and conclusion reached based on the investigation, and (3) document that the results of the investigation were reported to the Resident's Representative with a written grievance decision for 4 of 4 residents reviewed for grievances (Resident #125, #8, #33 and #46).

Inspectors wroteBased on observation, record review, Responsible Party interview, staff interviews and a Physician interview, the facility failed to protect Resident #1 from neglect by not implementing effective interventions to prevent a resident with a known diagnosis of PICA disorder (a mental health condition where a person compulsively eats non-food items that are harmful or toxic) from repeated incidents of accessing and ingesting medical examination gloves. On 2/21/2024, Resident #1 vomited two medical examination gloves. On 2/24/2024, a dime size object resembling a part of a medical examination glove was observed in Resident #1's enteral feeding (nutrition delivered through a tube placed into the stomach or small intestine) residual (enteral feeding not digested from the stomach). On 3/24/2024, Resident #1 vomited two medical examination gloves. [...]

Inspectors wroteBased on observation, record review, Responsible Party interview, staff interviews and a Physician interview, the facility failed to provide supervision to prevent a resident with a known diagnosis of PICA disorder (a mental health condition where a person compulsively eats non-food items that are harmful or toxic) from engaging in PICA behaviors. On 2/21/2024, Resident #1 vomited two medical examination gloves. On 2/24/2024 a dime size object resembling a part of a medical examination glove was observed in Resident #1's enteral feeding (nutrition delivered through a tube placed into the stomach or small intestine) residual (enteral feeding not digested from the stomach area). On 3/24/2024, Resident #1 vomited two medical examination gloves. On 4/5/2024 Resident #1 was found lying in bed with a medical examination glove in vomit under the edge of her pillow. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to report allegations of neglect to the state agency within the required timeframe. Additionally, the facility failed to report allegations of neglect to Adult Protective Services (APS) and law enforcement. This deficient practice was for 1 of 3 resident reviewed for neglect.

Inspectors wroteBased on observations, record review, responsible party interview, staff interviews and a Physician interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions that the committee had put in place in the area of abuse and neglect (F600) following the complaint investigation survey of 11/7/2023 and the complaint investigation survey of 2/23/2024. This deficient practice was subsequently recited on the current complaint investigation survey of 4/21/2024. The continued failure during three federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assurance Program.

Inspectors wroteBased on record review, observation, staff interviews, and review of the facility's video footage the facility failed to protect the resident's right to be free from abuse when Resident #1 physically abused by Nurse Aide (NA) #1. On 2/8/24 Resident #1 was attempting to leave a common area of the facility when NA #1 stopped him from leaving by blocking the resident's exit, physically turning the resident around with her hands on his arms, and then proceeded to use the resident's ambulatory assistance device (gait vest) to forcefully move the resident 14 feet to the couch. NA #1 attempted to get Resident #1 to sit on the couch by using both hands to push on Resident #1's torso. Resident #1 resisted the seated position and attempted to stand back up twice. On the first instance, NA #1 again pushed the resident with both hands on the front of his torso to a seated position. [...]

Inspectors wroteBased on record review, observation, staff interview, and review of the facility's video footage, the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the complaint investigation survey of 11/7/23. The deficiency is in the area of prevention of staff to resident abuse (F600). The continued failure during two federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assurance Program.

Inspectors wroteBased on observations, record review, and staff, responsible party, and physician interviews the facility failed to protect a resident's right to be free from staff (Nurse Aide #2) to resident verbal abuse. This was for 1 of 3 residents (Resident #1) investigated for abuse.

Inspectors wroteBased on record review and staff interviews the facility failed to implement their abuse policy for reporting an abuse allegation and failed to provide protection for all residents after an abuse allegation was made. This was for 1 of 3 residents (Resident #1) investigated for abuse.

Inspectors wroteBased on observations and staff interviews, the facility failed to discard expired food items from reach-in refrigerators (Cluster 1 Kitchen 101 and Cluster 2 Kitchen 201 and Kitchen 202) and dry storage area (Cluster 2 Kitchen 204) in 4 of the 10 kitchens observed at the facility. This practice had the potential to cause food borne illness. Findings Included: 1. On 8/14/2023 at 11:43 a.m. in Cluster 1 Kitchen 101, one unopened package of boiled eggs dated used by 7 [DATE] (8/7/2023) and one unopened package of boiled eggs dated used by 9 [DATE] (8/9/23) were observed in the reach-in refrigerator. In an interview with Dietary [NAME] #1 on 8/14/2023 at 11:43 a.m., she read the expirations for the packaged boiled eggs as expiring August 23rd. When asked what the number 7 and 9 were before the initials Aug on the package, she explained the eggs were to be used by 8/7/2023 and 8/9/2023. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure medications were under direct observation when Nurse #5 left medications unattended on the medication cart while she administered medications for 1 of 1 medication administration passes reviewed for medication storage.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide a written notice of transfer/discharge for residents who were transferred from the facility to the resident's representative or guardian and the ombudsman for 3 of 3 residents reviewed for hospitalization (Resident #14, Resident #15, and Resident #281).