O'Brien Memorial Health Care C

Inspectors wroteBased on medical record review, observation, interview, and review of medication manufacturer guidelines and facility policy, the facility failed to ensure Resident #25 was free of a significant medication error. This affected one resident (Resident #25) out of seven residents observed for medication administration. The facility census was 73.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to have documented evidence that nonpharmacological interventions were attempted prior to administering opioid pain medication for Resident #12. This affected one resident (#12) of five reviewed for unnecessary medications. The facility census was 68.

Inspectors wroteBased on closed medical record review, review of the acute care hospital paperwork, facility policy review and interview, the facility failed to provide care per physician's orders and failed to timely identify and address a change in condition for Resident #71 resulting in hospitalization. Actual Harm occurred on 03/16/25 when Resident #71 began displaying changes in his baseline mentation, eating patterns, and activity level and staff failed to document, notify the physician and/or timely address the change in condition resulting in Resident #71 continuing to decline without physician notification through 03/22/25 when Resident #71 was transferred to an acute care hospital at the insistence of his family and was diagnosed with sepsis related to aspiration pneumonia and acute metabolic encephalopathy.

Inspectors wroteBased on interview, documentation of Registered Nurse (RN) coverage review, Payroll Based Journal (PBJ) review and Facility Annual Assessment review, the facility failed to ensure there was adequate RN coverage for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 68 residents residing in the facility.

Inspectors wroteBased on observation, interview, and policy review the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to effect 75 of the 77 residents who ate food prepared in the kitchen. Residents #13 and #18 did not take any nourishment by mouth.

Inspectors wroteBased on observation, interview, and facility policy review the facility failed to ensure foods were stored in a manner to prevent contamination and foodborne illness. This had the potential to affect all residents who received food from the kitchen. The facility identified two residents (#27 and #36) who received no food by mouth. The facility census was 81.

Inspectors wrote3. Review of medical record for Resident #15 revealed an admission date of 05/30/24 with diagnoses including non-pressure chronic ulcer of the right foot, cellulitis (skin infection) of the left lower limb, diabetes mellitus, and peripheral vascular disease. Observation on 06/12/24 at 11:30 A.M. with RN #1275 of intravenous (IV) medication administration to Resident #15 revealed he had a central line venous catheter (a line that is inserted into a vein that leads to the heart). On Resident #15's door leading into the room there was a sign that stated he was on EBP that instructed staff to wear gown and gloves if there was device care including the use of central lines. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure medications were disposed of when they had expired. This affected 12 residents (#15, #32, #53, #72, #78, #177, #178, #180, #226, #227, #228, and #276) who had received expired tuberculin tests (medication to test for tuberculosis) with the potential to affect all residents in the facility. The facility census was 81.

Inspectors wroteBased on observation, interviews, record review, review of facility self-reported incidents (SRIs), and facility policy review the facility failed to ensure physician's orders were followed to prevent potential resident-to-resident abuse. This affected three residents (#7, #21, and #37) of 18 residents reviewed for abuse. This had the potential to affect three other residents (#18, #19, and #67) on the 400-Unit. The facility census was 81.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to maintain a functioning alarm for Resident #38 as ordered by the physician. This affected one resident (#38) out of four residents reviewed for alarms. The facility census was 81.

Inspectors wroteBased on record review, interviews, and facility policy review the facility failed to ensure Resident #2 was free of significant medication errors. This affected one resident (#2) of 33 residents reviewed during the annual survey. The facility census was 81.

Inspectors wroteBased on record review and interview, the facility failed to ensure all employees had reference checks prior to hire. This affected seven of sixteen employees reviewed for abuse. This had the potential to affect all 81 residents residing in the facility.

Inspectors wroteBased on employee personnel file review and interview, the facility failed to ensure State Tested Nurse Aide (STNA) evaluations were completed within 90 days of hire and annually. This affected six STNA's of six reviewed for performance. This had the potential to affect all 81 residents residing in the facility.

Inspectors wroteBased on personnel file review and interview, the facility failed to ensure Licensed Practical Nurse (LPN) #1229 had an active and unrestricted nursing license prior to hire. This affected one of three personnel files reviewed for staff qualifications. This had the potential to affect all residents residing in the facility. The facility census was 81.

Inspectors wroteBased on record review, review of the facility Self-Reported Incident (SRI), interview with facility staff, and review of the facility's policy on abuse, the facility failed to ensure Resident #65 and Resident #87 were free from sexual abuse. This affected three residents (Resident #27, Resident #65, and Resident #87) of three residents reviewed for sexual abuse. The facility census was 85.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents were free from significant medication errors. This affected two residents (#47 and #86) out of six residents observed and reviewed for medications. The facility census was 85.

Inspectors wroteBased on record review, review of the facility self-reported incident (SRI), review of associated investigations, interview with facility staff, and review of the facility's policy on abuse, the facility failed to provide appropriate supervision for Resident #55 to prevent sexual abuse of Resident #84. This resulted in Immediate Jeopardy on 02/16/24 at approximately 8:30 A.M. when Resident #55 was observed in Resident #84's room with his hand on Resident #84's vaginal area while Resident #84 said no, stop. This affected one resident (#84) reviewed for sexual abuse. The facility census was 83. On 02/26/24 at 2:16 P.M., the Administrator and Corporate Quality Assurance (QA) Nurse were notified Immediate Jeopardy began on 02/16/24 when Resident #84 was observed against the wall in her room between two beds and with Resident #55 in his wheelchair in front of her. [...]

Inspectors wroteBased on observation, interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidance the facility did not ensure staff followed proper isolation precautions while entering and exiting rooms for five (Resident's #21, #49, #79, #83 and #238) and the facility failed to ensure staff used proper handwashing guidelines during wound care for Resident #32. This affected six (Resident's #21, #32, #49, #79, #83 and #238) and had the potential to affect all 81 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a representative of the Office of the State Long-Term Care Ombudsman was notified of facility initiated discharges. This affected 43 residents (Resident's #17, #20, #36, #42, #43, #67, #68, #69, #80, #88, #240, #241, #242, #243, #244, #245, #246, #247, #248, #249, #250, #251, #252, #253, #254, #255, #256, #257, #258, #259, #260, #261 #262, #263, #264, #265, #266, #267, #268, #269, #270, #271 and #272). The facility census was 81.

Inspectors wroteBased on observation, record review, interview, and policy review the facility failed to ensure call lights were within reach of residents. This affected three (Resident's #12, #32 and #238) of three residents reviewed for call lights. The facility census was 81.

Inspectors wroteBased on interview, record review, review of the facility self-reported incident (SRI), and policy review the facility failed to ensure an allegation of abuse for Resident #57 was reported timely. This affected one (Resident #57) of one resident reviewed for abuse. The facility census was 81.

Inspectors wroteBased on interview and record review the facility failed to provide Resident #37 with showers twice a week as scheduled. This affected one (Resident #37) of three (Residents #20, #37, #47) reviewed for showers. The facility census was 81.

Inspectors wroteBased on record review and interview, the facility failed to complete pre and post dialysis assessments for Resident #75. This affected one (Resident #75) of two residents receiving dialysis treatments. The facility census was 81.