Berlin Nursing and Rehabilitation Center

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to store and label food items to maintain the integrity of the specific items. This was evident during the initial tour of the kitchen. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on interviews and record reviews it was determined that the facility failed to ensure Residents received accurate comprehensive assessments. This was found to be evident for 4 (Resident #74, #83,#100 & #11) out of 19 Residents reviewed for accuracy of assessment during the re-certification survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to develop and implement comprehensive care plans. This was found to be evident for 3 (Resident #6, #8, & #44) out of 19 Residents reviewed for Care Plans during the re-certification survey.

Inspectors wroteBased on interviews and record reviews it was determined that the facility failed to ensure timely and accurate documentation of medical records. This was found to be evident for 3 (#42, #2, #6, & #96) out of 5 residents reviewed for record documentation during the annual survey.

Inspectors wroteBased on surveyor observation, facility staff interview and surveyor record review it was determined that the facility staff failed to ensure the dignity of a Resident. This finding was found to be evident for 1 (Resident #68) out of 1 Resident reviewed for Resident Rights.

Inspectors wroteBased on interviews and record reviews it was determined that the facility failed to ensure showers were provided to a Resident as scheduled. This was found to be evident for 1 (Resident #65) out of 1 Resident reviewed for self-determination during the recertification survey.

Inspectors wroteBased on record reviews and interviews it was determined that the facility failed to ensure complete medical records were provided in a timely manner. This was found to be evident for 1 (Resident # 107) out of 1 Resident reviewed for medical records during the re-certification survey.

Inspectors wroteBased on record reviews, and interview, it was determined that the facility failed to develop and implement a Baseline care plan for a resident requiring hemodialysis treatments. This was evident for 1 (Resident #69) out of 2 residents requiring hemodialysis treatments reviewed during the annual recertification survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to review and revise the Interdisciplinary Care Plans to reveal accurate interventions for Residents. This was evident for 2 (Resident #69 & #5) out of 19 Residents reviewed for care plan timing and revision.

Inspectors wroteBased on observation and interviews it was determined that the facility failed to ensure care provided to a Resident met the professional standards of practice. This was found to be evident for 2 (Resident #65 & #55) out of 2 Residents reviewed for Services Provided Meet Professional Standards during the re-certification survey.

Inspectors wroteBased on observation, record review and interviews, it was determined that the facility failed to ensure that dependent residents' grooming needs were met in accordance with the residents' plan of care. This was evident in 1 (Resident# 69) of 1 resident reviewed for Activities of Daily Living (ADL).

Inspectors wroteBased on observation, record review and interview, it was determined that the facility failed to 1) obtain an order for the use of a splint and 2) properly assess and address the resident's condition prior to hospital transfer. This was evident for 2 (Resident #44 and #96) of 2 resident reviewed for position and mobility and 1 resident reviewed for hospitalization during the recertification survey.

Inspectors wroteBased on observation, interviews and record reviews it was determined that the facility failed to ensure a Resident received audiology services. This was found to be evident for 1 (Resident #74) out of 1 Resident reviewed for treatment to maintain hearing during the annual recertification survey.

Inspectors wroteBased on record reviews and interviews it was determined that the facility failed to ensure Residents received proper dialysis care. This was found to be evident for 2 (Resident #6 & #69) out of 2 Residents observed for dialysis care during the recertification survey.

Inspectors wroteBased on review of Geriatric Nursing Assistant personnel files and staff interview, it was determined that the facility staff failed to conduct yearly performance reviews at least every 12 months for 1 (Staff#21) of 5 staff members reviewed.

Inspectors wroteBased on staff interview and surveyor record review it was determined that the facility failed to act on recommendations from pharmacist drug regimen review reports. This finding was found to be evident in 1 (Resident #12) out of 1 Resident reviewed for unnecessary medication.

Inspectors wroteBased on surveyor observation and facility staff interview it was determined that the facility failed to 1) label/store drugs and biologicals appropriately and 2) properly secure medications. This finding was found to be evident during the review of medication administration and storage during the annual recertification survey.

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that the facility failed to ensure policies and procedures were followed to reduce the risk of infection. This was evident for 2 (Resident #6, #2) out of 4 residents reviewed for infection control procedures.

Inspectors wroteBased on record reviews and interviews it was determined that the facility failed to ensure medications were administered as ordered. This was found to be evident for 1 (Resident #102) out of 1 Resident reviewed for a significant medication error during the re-certification survey. This deficient practice resulted in an actual harm cited as past compliance.

Inspectors wroteBased on review of the facility's records and interview, it was determined that the facility failed to ensure Residents were free from abuse. This was found to be evident for 2 (Resident #108 & #7) out of 4 Residents reviewed for abuse during the re-certification survey.

Inspectors wroteBased on review of facility investigation documentation and medical records; interviews and observations, it was determined the facility failed to have an effective system in place to prevent residents with cognitive impairment from leaving the facility (Resident #41) and failed to supervise a resident outside who had been assessed to be an elopement risk (Resident #4). This failure lead to Resident #41 eloping from the facility on 8/16/23 and Resident #4 self- propelling down the facility driveway on 8/26/22 causing the Resident harm. This deficient practice was evident for 2 of 9 residents reviewed for elopement/wandering during a complaint survey. These actions resulted in the finding of an Immediate Jeopardy (IJ) which was identified on 9/19/23 at 4:20 PM for Resident #41 and 9/21/23 at 10:50 AM for Resident #4. [...]

Inspectors wroteBased on a review of complaints MD00196300, MD00194233, facility-reported incidents MD00196345, MD00193981, hospital records, medical record, facility documentation and interviews, it was determined the facility failed to protect a vulnerable resident ' s skin from injury resulting in harm to Resident #44, and failed to put measures in place to prevent further skin breakdown (Resident #38, #39, #23, #13). This was evident for 5 ( #44, #38, #39, #23, #13) of 43 residents reviewed during a complaint survey.

Inspectors wroteBased on observation, interviews, medical record review and review of facility documents, it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This has the potential to affect all the residents in the facility.

Inspectors wroteBased on interview, observation and record review, it was determined that the facility administration failed to provide effective oversight activities for the facility to ensure that resources were used effectively in order to meet the health and safety needs of each resident and identify and correct inappropriate care processes/standards, as evidenced by failing to 1) ensure that the facility had sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, and 2) failing to prevent elopement from the facility by recognizing, analyzing and developing a plan to ensuring all staff are educated on appropriate supervision of a resident and prevent future elopement.

Inspectors wroteBased on review of facility records and interview with staff, it was determined the facility failed to conduct and document an accurate facility-wide assessment. This was evident during the review of the Staff training, education and competencies, staffing and all-hazard assessment during the complaint and the extended survey. This has the potential to affect all residents within the facility.

Inspectors wroteBased on record review and interview it was determined the facility failed to report allegations of abuse within 2 hours of the allegation and an injury of unknown origin within 24 hours to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 9 (#44, #16, #28, #43, #42, #34, #22, #26, #9) of 43 facility reported incidents reviewed during a complaint survey.

Inspectors wroteBased on record review and interview it was determined that the facility failed to provide residents and or resident's responsible party (RP) a copy of their baseline care plan along with a copy of their admission medications. This was evident for 6 (#38, #40, #41, #23, #33, #45) of 48 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review, interview, and observation, it was determined that the facility staff failed to create and implement care plans related to resident's specific needs. This was evident for 6 (#38, #37, #28, #39, #23, #45) of 48 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to ensure the physician wrote, dated, and signed progress notes at each resident's visit. This was evident for 7 (#38, #42, #31, #32, #39, #41, #23) of 48 residents reviewed during a complaint survey.

Inspectors wroteBased on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews at least every 12 months for 5 out of 5 personnel files (GNA #9, #35, #40, #41 and #42) reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 4 (#37, #41, #39, #1) of 48 residents reviewed during a complaint survey.

Inspectors wroteBased on review of a complaint, observation of resident rooms, and interviews, it was determined that the facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of infection and disease. This was evident on 2 of 3 nursing units observed.

Inspectors wroteBased on observations, interviews, and documentation review, it was determined the facility failed to have an effective pest control program as evidenced by numerous flies seen throughout the facility. This was evident on 2 of 3 nursing units observed during a complaint survey.

Inspectors wroteBased on facility documentation review and interview, it was determined the facility failed to develop, implement and maintain an effective training program for all new and existing staff. This has the potential to affect all residents in the facility.

Inspectors wroteBased on a review of a complaint and facility reported incident, medical record review, and interview, it was determined the facility staff failed to notify the physician in a timely manner for a resident's acquisition of pressure ulcers, a change in condition, and abnormal vital signs. This was evident for 3 (#39, #41, #13) of 48 residents reviewed during a complaint survey.

Inspectors wroteBased on review of a complaint, observation of resident rooms and equipment, and interviews, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident on 1 of 3 nursing units observed.

Inspectors wroteBased on review of facility reported incidents, record review and interview with facility staff, it was determined that the facility failed to provide the residents with an environment that was free of misappropriation of property. This was evident for 1 (#29) of 48 residents reviewed during a complaint survey.

Inspectors wroteBased on review of facility administrative records, facility investigations, and staff interview, it was determined the facility failed to thoroughly investigate incidents of alleged abuse and neglect. This was evident for 3 (#34, #23, #1) of 48 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review, observation and staff interview, it was determined the facility staff failed to accurately revise a resident's care plan for wandering (Resident #7). This was evident for 1 of 5 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review, observation and interview, the facility staff failed to perform activities of daily living for a dependent resident (Resident #12). This was evident for 1 of 3 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to follow the hospital discharge summary and obtain blood work when ordered and apply an ice pack as ordered to a resident's surgical site. This was evident for 2 (#39, #45) of 48 residents reviewed during a complaint survey.

Inspectors wroteBased on review of a complaint, a closed medical record, and staff interviews, it was determined that the facility staff failed to timely obtain pain medication and failed to perform pain assessments for a newly admitted resident after having surgery. This was evident for 1 (#40) of 48 residents reviewed during a complaint survey.

Inspectors wroteBased on review of complaint MD00194719, medical record review, and interviews, it was determined the facility failed to ensure that pain medications were available to a resident upon admission to the facility. This was evident for 1 (#40) of 6 residents reviewed for a complaint during a complaint survey.

Inspectors wroteBased on observation, staff interview, and documentation review it was determined that facility staff failed to keep medication and treatment carts locked when unattended. This was evident on 1 of 4 nursing units observed during random observations made during a complaint survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to notify the physician with the laboratory results of a CBC (complete blood count) that were outside of clinical reference ranges. This was evident for 1 (#39) of 6 residents reviewed for a complaint during a complaint survey.

Inspectors wroteBased on observation, staff interview, and documentation review, it was determined that the facility failed to post the the resident census and total number and actual hours worked by categories of Registered nurses, Licensed practical nurses, and Certified nursing aides at the beginning of the shift. This was evident for the facility and on 2 of 3 nursing units during a complaint survey.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure that the residents or resident's representatives were notified in writing of reason residents are being transferred out of the facility to an acute care hospital. This was found to be evident for 4 out of 4 residents records reviewed for hospitalization involving Resident's (R#72), (R#74), (R#284) and (R#287) reviewed during the investigative portion of the survey process.

Inspectors wroteBased on observation, medical record review and interviews it was determined that the facility failed to revise and update care plan that addressed residents after change in condition (Resident #72, #284, #74, #6 and #48). This was evident 5 out of 31 residents reviewed during an annual survey.

Inspectors wroteBased on observation, medical record review and interview, the facility staff failed to ensure residents receive treatment and services in accordance with professional standards of practice (Resident #26, #48, #443, #22, #70, #9 and #389). This was evident for 7 out of 71 residents reviewed during an annual survey.

Inspectors wroteBased on clinical record review, resident review, and staff interview it was determined that the facility staff failed to ensure resident wishes for showers were honored (#6 and #52). This was evident for 2 out of 71 residents in the survey sample.

Inspectors wroteBased on resident and staff interview, it was determined the facility staff failed to have petty cash available to Resident #40. This was evident for 1 of 1 resident selected for review of Personal Funds and 1 of 71 resident selected for review during an annual survey.

Inspectors wroteBased on resident council meeting, tour of the facility, and staff interviews it was determined that the facility staff failed to ensure residents are informed of the results to the state surveys as well as signage to inform the residents of the location of the state survey results.

Inspectors wroteBased on medical record review it was determined the facility staff failed to transmit a MDS assessment to the Centers of Medicare/Medicaid (CMS) within 14 days of completion for Resident #1. This was evident for 1 of 71 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review it was determined that the facility staff failed to initiate care plan for Resident #70 for communication. This was evident for 1 of 71 residents selected for review during the annual survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to administer medications to Resident #5 in accordance with the standard of nursing practice. This was evident for 1 of 3 residents selected for review during medication administration observation during the annual survey.

Inspectors wroteBased on observation and interview, it was determined the facility staff failed to provide Residents #59 and Resident #37 in a position conducive to eating. This was evident for 2 of 20 residents observed during tour of station during delivery of food trays on Station 1.

Inspectors wroteBased on medical record review, it was determined the facility staff failed to provide restorative nursing services that would allow Resident #31 the ability to achieve the greatest independence with performing Activities of Daily Living. This was evident for 1 of 2 residents selected for ADL decline and 1 of 2 residents selected for review of Range of Motion and 1 of 71 residents selected for review during the annual survey process.

Inspectors wroteBased on observation and medical record review it was determined the facility staff failed to provide grooming and personal hygiene services (Resident #27). This is evident for 1 of 3 residents selected for review of ADL care and 1 of 71 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #6). This is evident for 1 of 3 residents reviewed during a annual survey. A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed).

Inspectors wroteBased on medical record review and observations, it was determined the facility staff failed to provide fall mats next to the bed of Residents #22 and Resident #59. This was evident for 2 of 71 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and interview, the facility staff failed to obtain monthly weights as ordered, conduct an accurate readmission nutrition assessment and conduct all quarterly nutritional assessment by a licensed dietitian for a resident (Resident #41). This was evident for 1 out of 3 residents reviewed during the annual survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to obtain pre and post dialysis weights and vital signs for Resident (#27). This was evident for 1 of 1 resident selected for review of Hemodialysis and 1 of 71 selected for review during the annual survey process.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to ensure the medication carts are locked and secured. This was evident for 1 unit out of the 6 units in the facility.

Inspectors wroteBased on medical record review, observation and interview, the facility staff failed to obtain dental services for a resident (Resident #68). This was evident for 1 out of 20 residents reviewed for dental services during an annual survey.

Inspectors wrote2. The facility staff failed to maintain the medical record for Resident #27 in the most accurate form. Medical record review for Resident #27 on 6/1/22 at 11:30 AM revealed on 1/28/19 the physician ordered: Wanderguard placed regarding resident being transferred off of closed-unit. Wanderguard to be checked by nursing every shift for patency of said wanderguard. Continue with plan of care and monitoring. Further record review revealed the physical ordered: Inspect Wanderguard every shift to make sure it is in good working condition, If not, replace immediatley, every shift. The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. [...]

Inspectors wroteBased on observation, medical record review and staff interviews; It was determined that the facility staff failed to maintain a sanitary environment to prevent the development and transmission of infection in 1. storing and transporting of linen and 2. in the administration of medication (Resident #5). This was evident in 1 out of 2 clean linen carts observations and 1 out of 3 residents during medication administration during the annual survey.

Inspectors wroteBased on record review, observation and interview it was determined the facility staff failed to provide Resident #113 with the preferred flavor of dietary supplement. This was evident for 1 of 41 residents selected for review during the annual survey process.

Inspectors wroteBased on resident interview, staff interview, and observation it was determined that the facility staff failed to ensure furniture was maintained in a clean fashion.

Inspectors wroteBased on medical record review and interviews, it was determined the facility staff failed to administer pain medication as ordered by the physician and failed to evaluate the effectiveness of that pain medication in a timely manner for Resident #376. This was evident for 1 of 41 residents reviewed during the survey process and 1 of 7 residents reviewed during a complaint survey (MD 00127697).

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to obtain a medication error rate below 5%. Based on observation of medication pass, it was determined the medication error rate was 5.88%. This was evident for 1 of 3 residents observed and 2 out of 34 opportunities (Resident #116).

Inspectors wroteBased on observation, and interview with staff it was determined that the facility failed to maintain all essential mechanical, electrical, equipment in safe operating condition on the lower level of the facility.