O'Neill Healthcare Lakewood

Based on resident record review, staff interviews, facility investigation review, and facility policy review, the facility failed to ensure medications were given as ordered and given to the correct resident. This affected two residents (#12 and #42) of three residents reviewed for medication administration. The facility census was 53. Findings include: 1. Review of the medical record for Resident #12 revealed he was admitted to the facility on 10/31/22 with diagnoses that included anxiety disorder, type two diabetes, and bipolar disorder. Review of the service plan dated 10/22/25 revealed Resident #12 required staff nurses to assist and provide all medications. Review of the progress note dated 10/25/25 at 1:34 P.M. revealed the nurse, identified as Licensed Practical Nurse (LPN) #607, at approximately 12:00 P.M., administered bupropion to Resident #12. Upon further review of the medication order, it was discovered that Resident #12 was the incorrect resident to receive the medication. LPN #607 notified Resident #12's physician and was advised to monitor Resident #12 for adverse effects. Review of the physician orders for the month of October 2025 revealed no orders for bupropion or buspirone hydrochloride. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 10/01/25 through 12/01/25 revealed no discontinued and/or canceled orders for bupropion or buspirone hydrochloride. 2. Review of the medical record for Resident #42 revealed he was admitted to the facility on 01/22/25 with diagnoses that included encephalopathy, major depressive disorder, and generalized anxiety disorder. Review of the service plan dated 12/15/25 revealed Resident #42 required staff nurses to assist and provide all medications. Review of the physician orders dated 06/12/25 revealed an order for buspirone hydrochloride 7.5 milligrams (mg) oral tablet to be given by mouth three times a day for depression. Review of the physician orders for the month of October 2025 revealed no orders for bupropion. According to the National Institutes of Health (NIH), www.nih.gov, Buspirone was an antianxiety medication used to treat generalized anxiety disorder. Review of the facility investigation labeled, Pharm Med Error w/o Adverse RxtnBased on resident record review, staff interviews, facility investigation review, and facility policy review, the facility failed to ensure medications were given as ordered and given to the correct resident. This affected two residents (#12 and #42) of three residents reviewed for medication administration. The facility census was 53.

Findings include:

1. Review of the medical record for Resident #12 revealed he was admitted to the facility on 10/31/22 with diagnoses that included anxiety disorder, type two diabetes, and bipolar disorder.

Review of the service plan dated 10/22/25 revealed Resident #12 required staff nurses to assist and provide all medications.

Review of the progress note dated 10/25/25 at 1:34 P.M. revealed the nurse, identified as Licensed Practical Nurse (LPN) #607, at approximately 12:00 P.M., administered bupropion to Resident #12. Upon further review of the medication order, it was discovered that Resident #12 was the incorrect resident to receive the medication. LPN #607 notified Resident #12's physician and was advised to monitor Resident #12 for adverse effects.

Review of the physician orders for the month of October 2025 revealed no orders for bupropion or buspirone hydrochloride.

Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 10/01/25 through 12/01/25 revealed no discontinued and/or canceled orders for bupropion or buspirone hydrochloride.

2. Review of the medical record for Resident #42 revealed he was admitted to the facility on 01/22/25 with diagnoses that included encephalopathy, major depressive disorder, and generalized anxiety disorder.

Review of the service plan dated 12/15/25 revealed Resident #42 required staff nurses to assist and provide all medications.

Review of the physician orders dated 06/12/25 revealed an order for buspirone hydrochloride 7.5 milligrams (mg) oral tablet to be given by mouth three times a day for depression.

Review of the physician orders for the month of October 2025 revealed no orders for bupropion.

According to the National Institutes of Health (NIH), www.nih.gov, Buspirone was an antianxiety medication used to treat generalized anxiety disorder.

Review of the facility investigation labeled, Pharm Med Error w/o Adverse Rxtn

Based on observations, resident interviews, staff interviews, facility policy review, and review of the monthly weather forecast, the facility failed to maintain safe and comfortable temperature levels in resident utilized areas. This had the potential to affect all residents residing in the facility. The facility census was 53. Findings include: Observations on 01/30/26 from 2:10 P.M. to 2:45 P.M. with Maintenance Director (MD) #806, during initial tour of the facility revealed the following: The hallway located on the first floor near Room #103 had a temperature reading of 65 degrees Fahrenheit (F). The resident utilized men's bathroom, located on the second floor, had a temperature reading of 68 degrees (F). The resident utilized spa located on the third floor had a temperature reading of 65 degrees (F). The central hallway located on the fourth floor had a temperature reading of 65 degrees (F). The area located directly outside Room #415 had a temperature reading of 69 degrees (F). Interview at the time of the observations with MD #806 verified the above findings. Interview on 02/03/26 at 9:34 A.M. with MD #806 revealed he was made aware of a couple of complaints from residents regarding the heat in the building last week (01/25/26 to 01/31/26) but could not confirm the actual day. Rooms #401 and #403 were without heat for an hour and portable heaters were used until he fixed the problem. The pressure was low on the boiler and sometimes it required water to be added to the system. MD #806 bumped up the temperature in the building, removed the air out of the line on the fourth floor and everything was good until Sunday, 02/01/26 when the heating system was not operating at its full potential. Resident rooms located at the end of the halls were cold, and with the windchill being -5 degrees (F), it was hard to control the temperature in the building. However, MD #806 stated there were no current issues with the temperatures in the facility at the time of the survey and it was not of major concern. MD #806 explained he could not adjust the Pounds per Square Inch (PSI) or add water due to the PSI currently at 45 or it would blow up. MD #806 stated there was little he could do and there was no preplanning for keeping the facility warm during frigid temperatures. MD #806 revealed due to the structure and the layout of the building, it caused the building to not maintain its heating source, indicating that the outer walls of the building faced a certain way caused the drop in temperature during the winter months. MD #806 revealed there was no documentation verification to indicate the facility fixed issues related to the boiler and/or the heating system. MD #806 stated some residents were provided with portable heaters temporarily as the elderly can get cold even when its 90 degrees (F) in the roomBased on observations, resident interviews, staff interviews, facility policy review, and review of the monthly weather forecast, the facility failed to maintain safe and comfortable temperature levels in resident utilized areas. This had the potential to affect all residents residing in the facility. The facility census was 53.

Findings include:

Observations on 01/30/26 from 2:10 P.M. to 2:45 P.M. with Maintenance Director (MD) #806, during initial tour of the facility revealed the following:

The hallway located on the first floor near Room #103 had a temperature reading of 65 degrees Fahrenheit (F).

The resident utilized men's bathroom, located on the second floor, had a temperature reading of 68 degrees (F).

The resident utilized spa located on the third floor had a temperature reading of 65 degrees (F).

The central hallway located on the fourth floor had a temperature reading of 65 degrees (F).

The area located directly outside Room #415 had a temperature reading of 69 degrees (F).

Interview at the time of the observations with MD #806 verified the above findings.

Interview on 02/03/26 at 9:34 A.M. with MD #806 revealed he was made aware of a couple of complaints from residents regarding the heat in the building last week (01/25/26 to 01/31/26) but could not confirm the actual day. Rooms #401 and #403 were without heat for an hour and portable heaters were used until he fixed the problem. The pressure was low on the boiler and sometimes it required water to be added to the system. MD #806 bumped up the temperature in the building, removed the air out of the line on the fourth floor and everything was good until Sunday, 02/01/26 when the heating system was not operating at its full potential. Resident rooms located at the end of the halls were cold, and with the windchill being -5 degrees (F), it was hard to control the temperature in the building. However, MD #806 stated there were no current issues with the temperatures in the facility at the time of the survey and it was not of major concern. MD #806 explained he could not adjust the Pounds per Square Inch (PSI) or add water due to the PSI currently at 45 or it would blow up. MD #806 stated there was little he could do and there was no preplanning for keeping the facility warm during frigid temperatures. MD #806 revealed due to the structure and the layout of the building, it caused the building to not maintain its heating source, indicating that the outer walls of the building faced a certain way caused the drop in temperature during the winter months. MD #806 revealed there was no documentation verification to indicate the facility fixed issues related to the boiler and/or the heating system. MD #806 stated some residents were provided with portable heaters temporarily as the elderly can get cold even when its 90 degrees (F) in the room

Based on personnel file review, staff interviews, and facility policy review, the facility failed to ensure tuberculosis testing of new employees prior to the first day of work. This had the potential to affect all residents residing in the facility. The facility census was 51.

Findings include:

1. Review of the personnel file for Laundry Aide (LA) #808 revealed a hire date of 09/26/23. Review of the Mantoux 2-Step Tuberculosis (TB) Test revealed LA #808 received the first test on 10/20/23 and results were read on 10/23/23. LA #808 second test was administered on 11/06/23 and results were read on 11/09/23. Review of the TB test results revealed she started working prior to the reading of her test results. LA #808 started working approximately 27 days prior to the TB testing.

2. Review of the personnel file for Patient Care Assistant (PCA) #804 revealed a hire date of 10/16/24. Review of the Mantoux 2-Step TB Test revealed she received her first test on 11/05/24 and results were read on 11/08/24. PCA #804 second test was administered on 11/18/24 and results were read on 11/20/24. Review of the TB test results revealed she started working prior to the reading of her test results. PCA #804 started working approximately 21 days prior to the TB testing. TB testing should occur prior to the first day of work.

3. Review of the personnel file for PCA #815 revealed a hire date of 10/02/24. Review of the Mantoux 2-Step TB Test revealed she received her first test on 10/02/24 and results were read on 10/05/24. PCA #815 second test was administered on 10/16/24 and results were read on 10/18/24. Review of the TB test results revealed she started working prior to the reading of her test results. PCA #815 started working approximately three days prior to the results of the TB testing. TB testing should occur prior to the first day of work.

4. Review of the personnel file for Licensed Practical Nurse (LPN) #819 revealed a hire date of 03/27/24. Review of the Mantoux 2-Step TB Test revealed she received her first test on 04/25/24 and results were read on 04/28/24. LPN #819 second test was administered on 05/09/24 and results were read on 05/11/24. Review of the TB test results revealed she started working prior to the reading of her test results. LPN #819 started working approximately 30 days prior to the TB testing. TB testing should occur prior to the first day of work.

Review of the personnel files revealed LPN #819 and LA #808 did not have an annual TB screening.

Interview on 07/16/25 at 12:55 P.M. with the Director of Nursing (DON) confirmed and verified the dates of hire and the above findings at the time of the review of the personnel files.

Interview on 07/16/25 at 1:13 P.M. with the Human Resource Director (HRD) #831 revealed during review of the personnel files confirmed and verified the above findings.

Based on record review and staff interview, the facility failed to ensure an inspection of the central heating system was completed. This had the potential to affect all 51 residents residing in the facility.

Findings include:

Review of the documents provided by Executive Director (ED) in regard to the annual survey revealed no documented evidence of an inspection of the central heating system.

Interview on 07/16/25 at 10:45 A.M. with the Maintenance Director (MD) #830 revealed there was no inspection of the central heating system. MD #839 confirmed and verified the above findings at the time of the interview.