Berkley Care Center

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the upstairs kitchen. Specifically, the facility failed to:-Ensure dietary staff performed appropriate hand hygiene during meal service; and,-Ensure the rims of cups were not touched by staff when serving beverages.

Inspectors wroteBased on record review and interviews, the facility failed to meet all requirements for the provision of hospice care for three (#3, #58 and #33) of three residents reviewed for hospice services out of 41 sample residents. Specifically, the facility failed to ensure hospice notes were readily accessible and the comprehensive care plan was developed with delineation of care responsibilities established between the facility and hospice for Resident #3, Resident #58 and Resident #33.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to:-Ensure housekeeping staff cleaned and disinfected residents' rooms in a hygienic manner; -Ensure housekeeping staff performed appropriate hand hygiene while cleaning residents' rooms; -Ensure a urine spill in the dining room was cleaned and disinfected in an appropriate manner; and,-Ensure urinary catheter bags were stored in a sanitary manner in residents' rooms.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide the necessary services to maintain personal hygiene for one (#23) of four residents reviewed for services to maintain the highest practicable quality of life out of 41 sample residents. Specifically, the facility failed to ensure Resident #23 received timely incontinence care.

Inspectors wroteBased on record review and interviews, the facility failed to clarify resuscitation choices and document them accurately in the medical records for two (#53 and #11) of two residents reviewed for advance directives out of 41 sample residents. Specifically the facility failed to:-Ensure Resident #53 and Resident #11's medical orders for scope of treatment (MOST) forms matched their physician's orders; and,-Ensure staff were able to locate the residents' MOST forms in order to follow the residents' choices for cardiopulmonary resuscitation (CPR).

Inspectors wroteBased on observations, record review and interviews, the facility failed to communicate effectively with the dialysis centers for two (#61 and #4) of two residents reviewed for dialysis out of 41 sample residents. Specifically, the facility failed to ensure dialysis communication forms between the facility and the dialysis center were thoroughly completed consistently for Resident #61 and Resident #4.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents who were trauma survivors, received culturally competent, trauma-informed care in accordance with professional standards or practice and accounting for the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#40) of two residents reviewed for trauma-informed care out of 41 sample residents. Specifically, the facility failed to ensure Resident #41 had a trauma-informed care plan which identified potential triggers that had the potential to re-traumatize the resident.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#17) of one resident out of 41 sample residents received dental services timely. Specifically, the facility failed to assist Resident #17 with finding another dental service that accepted his dental insurance.

Inspectors wroteBased on record review and staff interviews, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for one (#36) of five residents reviewed for immunizations out of 41 sample residents. Specifically, the facility failed to ensure Resident #36 received pneumococcal immunization when consent was given.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to assess and monitor an existing pressure injury for one (#50) of seven residents reviewed for wounds out of 32 sample residents and failed to take steps to prevent the resident's development of pressure injuries. Resident #50 who required hands on assisance from staff to complete activities of daily living such as toileting, bed mobility, dressing and personal hygiene and who was at high risk for developing pressure injuries developed facility acquired pressure injury. The resident's pressure injury was first discovered on 4/27/23 and started as a redness spread over the bony part of the resident's left hip. The wound care physician classified the wound as a trauma wound. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in one of two medication storage rooms. Specifically, the facility failed to ensure vaccines and insulins (medications used to regulate blood glucose levels) were not stored in a dormitory style fridge.

Inspectors wroteBased on observations and staff interviews, the facility failed to provide adequate outside ventilation by means of windows and/or mechanical ventilation. Specifically, the facility failed to ensure the soiled linen laundry room exhaust fan was functional.

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to ensure two (#54 and #4) of four residents reviewed for accident hazards out of 34 sample residents, were provided adequate supervision and a safe environment to prevent accidents and the re-occurrence of accidents. Resident #54 was admitted to the facility on [DATE] with a diagnosis and history of falls. The resident had four falls from 8/23/21 through 4/7/22. The facility failed to implement effective fall precautions with her risk of falling. On 4/7/22 the resident sustained a head injury following a fall which required hospital treatment. The interventions included educating the resident but also documented the resident was not always able to communicate her needs and that she forgot conversations held after a few minutes. The resident had a care plan to wear non-skid socks. [...]

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection, including COVID-19 in two of two floors. Specifically, the facility failed to: -Ensure visitors and staff who entered into the facility through the front lobby, reception area, wore masks; -Ensure residents were offered hand hygiene before meals in both the dining rooms and room trays; -Ensure resident bedrooms were cleaned with proper infection control techniques. The housekeeping staff wore the same gloves to clean rooms with double occupancy, and used the same cleaning rag throughout a double occupancy room; and, -Ensure proper personal protective equipment (PPE) were donned and doffed properly.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 26 of 53 resident rooms, six of six hallways. Specifically, the facility failed to ensure walls, baseboard cove, doors, floor tiles, and ceiling were repaired, painted and properly maintained: and failed to ensure resident's had clean bath linens.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure proper treatment and assistive devices to maintain vision and hearing abilities for two (#37 and #14) of two residents out of 34 sample residents. Specifically the facility failed to provide services to fix broken glasses for Resident #37 and #14.

Inspectors wroteBased on resident and staff interviews and record review, the facility failed to assist residents with either maintaining continence or ensuring appropriate treatment to restore continence to the extent possible for two (#14 and #46) of two residents reviewed of 34 sample residents. Specifically, the facility failed to offer and encourage Resident #14 and Resident #46 a toileting program to promote bladder continence.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for two (#54 and #33) of three residents out of 34 sample residents. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #54 and Resident #33.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that its medication error rate was not five percent or greater for observed medication administration. Specifically, the facility had a medication error rate of 6.9%, which was two errors out of 29 opportunities for error.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in two medication carts and one storage room. Specifically, the facility failed to ensure: -Medication or treatment carts were locked when the licensed nurse was not present; -Topical medications were labeled; -Topical medications were not stored on nurses desk; -Food was not stored in the medications storage areas; and, -Disinfectant was kept separate from medication.

Inspectors wroteBased on interviews and record review, the facility failed to test residents, facility staff, and individuals providing services under arrangement and volunteers for COVID-19. Specifically, the facility failed to ensure: -Rapid point-of-care (POC) tests for COVID-19 were consistently conducted on staff prior to the start of their shift, based on the facility's county positivity rate; and, -Staff implemented correct testing techniques with PCR (polymerase chain reaction) testing to ensure accurate results.

Inspectors wroteBased on observations and staff interviews, the facility failed to provide adequate outside ventilation by means of windows and/or mechanical ventilation. Specifically, the facility failed to ensure resident bathroom exhaust fans were functioning on three of six resident hallways.

Inspectors wroteBased on record review and interviews, the facility failed to ensure each resident had the right to formulate an advanced directive for three (#46, #54 and #4) of 24 residents reviewed out of the 34 sample residents. Specifically the facility failed to: -Ensure advanced directives for Residents #46, #54, and #4 were completed accurately. The facility utilized the medical orders for scope and treatment (MOST) for the resident's advance directives; -Have Resident #46 sign his advance directive as he was his only power of attorney: and, -Have a legal signature on Resident #54's advance directives when a physician designated a family member as the resident's authorized representative.

Inspectors wroteBased on observation, record review and interviews, the facility failed provide care and services for activities of daily living including speech, language and other communication systems for one (#14) out of 34 sample residents. Specifically, the facility failed to: -Ensure Resident #14 was able to communicate in her preferred language; and, -Ensure the communication book was available at Resident #14's bedside.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one (#62) of five residents reviewed for activities out of 34 sample residents. Specifically, the facility failed to ensure Resident #62 was invited and encouraged to attend activities of her preference.

Inspectors wroteBased on resident observations, record review and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for one (#17) of two residents reviewed for supplemental oxygen use out of 34 sample residents. Specifically, the facility failed to administer oxygen in accordance with the physician's order for Resident #17.

Inspectors wroteBased on record review and interviews, the facility failed to provide effective pain management services to one (#13) of 34 sample residents. Specifically, the facility failed to try more than one non-medication pain management interventions for Resident #13. I. Facility policy The Pain policy, revised on 7/17/21, was delivered by the nursing home administrator (NHA) on 7/16/22 at 10:40 a.m. It read in pertinent part: The purpose of pain assessment and management is to help residents maintain their highest practicable level of well being by managing pain indicators. Based on the comprehensive assessment of a resident, this facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident ' s choices related to pain management. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to monitor and document mood to prevent depression difficulties for one (#12) of six residents reviewed for mood/behaviors of 34 sample residents. Specifically, the facility failed to ensure the residents behavioral needs were person centered and individualized to meet his needs for depression.

Inspectors wroteBased on observations, record review and interviews, the facility failed to promptly provide, or obtain from an outside resource, routine and emergency dental services to meet the residents' needs for one out of 34 sample residents. Specifically, the facility failed to ensure Resident #14 received assistance to get her lower dentures repaired.