O'Brien Memorial Health Care C

In the surveyor’s words

From the most serious findings on record at O'Brien Memorial Health Care C, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 29, 2024

  Based 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. […]

• Actual harm, isolatedF684May 22, 2025

  Based 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, fecal impaction,… […]

• No harm, potential for more than minimal, widespreadF727Mar 14, 2025

  Based 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. Findings include: Review of the Facility Annual Assessment, dated 05/31/24, revealed under licensed nurses the facility would have one full-time Director of Nursing (DON), one full time Clinical Director (not specifying if this was an RN or Licensed Practical Nurse (LPN), and under the area of RN, they would have one full time Minimum Data Set (MDS) RN, one full time Restorative RN plus 100-136 hours of a RN per two weeks. […]

• No harm, potential for more than minimal, widespreadF812Aug 7, 2024

  Based 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. Findings include: Observations on 08/07/24 at 8:14 A.M., during a tour of the kitchen with the administrator, revealed multiple concerns with kitchen cleanliness. Of the two hand washing stations, both were unclean and there were water stains and soap scum on the sink and back splash and grime around the faucets and handles. The hand washing station located next to the rear exit door did not have paper towels. […]

• No harm, potential for more than minimal, widespreadF812Jun 13, 2024

  Based 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. Findings include: Observation on [DATE] at 8:04 A.M. of the kitchen revealed the following items open and undated in the dry storage area: one bag of potatoes, one bag of cornflakes, one bag of Cheerios, one box of pancake batter, three bags of pasta, and one jar of syrup. There were also three bags of hoagie buns that expired on [DATE]. […]