Berrien Oaks Nursing and Rehab Center

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure pureed meals were prepared according to standardized recipes and appropriate consistency requirements for eight of eight residents who received a pureed diet. Specifically, pureed meals were not consistently prepared or served in a manner that maintained appropriate texture, appearance, palatability, and safety for residents with swallowing difficulties. This deficient practice had the potential to affect all residents receiving pureed diets by placing them at risk for choking, aspiration, poor nutritional intake, and decreased quality of life.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Food Storage: Cold Food Items, the facility failed to ensure that food was properly labeled and dated and in sanitary conditions to prevent foodborne illness. The deficient practice had the potential to affect 94 residents of 95 who received meals from the kitchen.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure an indwelling Foley catheter drainage bag was covered to maintain dignity for one of three residents (R) (R57) reviewed for catheter care and dignity. This deficient practice had the potential to compromise the personal dignity of R57 by exposing clinical urinary waste to public view.

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility policy titled, Medication Storage, the facility failed to assess for and obtain a physician order for the ability to self-administer medications for one of 58 sampled residents (R) (R3). The deficient practice had the potential for residents and visitors to access medications and experience adverse effects.

Inspectors wroteBased on observations, record review, staff and family interviews, and review of the facility's policy titled, Elopement and Wandering Policy, the facility failed to ensure safety for one of 48 sampled residents (R106). Specifically, the facility failed to provide adequate supervision and monitoring for R106 related to wandering and elopement. This deficient practice had the potential to place R106 at risk for safety concerns including but not limited to physical and/or mental distress.

Inspectors wroteBased on observation, staff interview, record review, and review of the facility policy and procedure titled Medication Administration Policy- General, the facility failed to ensure that the medication error rate was less than five percent. A total of 30 opportunities were observed with six errors, for one of four residents (R) (R7) by one of three nurses, for a medication error rate of 16.6 percent.

Inspectors wrote2. Observation of the kitchen began on 4/14/2025 at 10:45 am and ended at 11:30 am. The following repairs needed were noted with the Dietary Manager (DM). Observation of walls on 4/14/2024 at 10:46 am of the dishwasher room revealed dirty floor tiles built up with dirt and grease, debris, and dirty walls, specially underneath the three-compartment sink and below the drying rack counter. Observation of the dishwasher door revealed a thick coating of rust. Observation of the chemical storage area on 4/14/2025 at 10:48 am revealed a dirty floor, large holes in the wall, and dark brown spots on the ceiling area. Observation of the kitchen exit door on 4/14/2025 at 10:50 am revealed the door failed to have a secure tight shut. Observation of the deep fryer on 4/14/2025 at 11:01 am revealed grease build up and a thick coating of rust on the side frame panel. [...]

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policy titled, Resident Rights, the facility failed to promote care in a manner that maintained or enhanced each resident's dignity and respect for two of 48 sampled residents (R) (R50 and R40). Specifically, staff provided personal hygiene and bathing assistance to R50 without providing full visual privacy and failed to ensure proper placement of a dignity bag for R40's catheter bag.

Inspectors wroteBased on record review, staff interviews, and review of the facility policies titled, Bed Hold Policy and Facility Policy/Procedures, the facility failed to ensure a bed hold notice was provided at the time of transfer to a hospital for one of three residents (R) (R40) reviewed for hospitalization.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Care Plan, the facility failed to ensure care plan developement for one of 48 sampled residents (R) (R40) related to a foley catheter. The deficient practice had the potential for R40's needs and services to go unmet.

Inspectors wroteBased on observations, record review, staff interview, and review of the facility's policy titled, Oxygen Administration, the facility failed to properly administer oxygen (O2) and properly maintain the oxygen concentrator for three of 14 residents (R) (R59, R53, and R40) currently using oxygen. The deficient practice had the potential of decreased blood oxygen levels, an increased risk of infection for the residents, and the danger of not knowing oxygen was in use.

Inspectors wroteBased on observations, staff interviews, and review of the facility's' policies titled, Date Marking for Food Safety and Food Nutrition Sanitation and Food Products, the facility failed to ensure ice was covered and transported in a sanitary manner, food items were properly stored, labeled, and dated, and expired food items disposed of in a timely manner. In addition, the facility failed to follow the manufacture guidelines for proper sanitation procedures with the 3-compartment sink and dishwasher for sanitation of washing cookware and dishes. The dietary equipment was maintained under sanitized conditions free from rust and a pedal push garbage container was accessible to staff. The flooring and walls of the facility were free from dirt and debris. The deficient practice had the potential to affect 83 of 87 residents receiving an oral diet.

Inspectors wroteBased on observations, resident and staff interviews, and review of the facility's policies titled, Oxygen Administration, Medication Administration, Medication Administration: Oral and Nasal Inhalations, Hand Hygiene, COVID-19 Prevention, Response and Reporting, and Water Management Policy the facility failed to ensure infection control measures were followed during the administration of nasal and oral inhalation medications for one of 29 residents (R) (R40), and hand hygiene was performed during medication administration for one of five residents (R40). The facility also failed to decrease the chance of COVID-19 spread by allowing two residents (R68 and R70) to cohort in the same rooms as positive tested COVID-19 residents (R64 and R65). [...]

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Disposal of Garbage and Refuse the facility failed to ensure that the dumpster area was maintained in sanitary conditions as it relates to dumpster lids being secured/tightly fitted at all times. The deficient practice had the potential to promote the harboring of pest, insects, and other organisms.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Oxygen Administration, the facility failed to provide oxygen therapy as ordered for one of 27 Residents (R) (R17) that were receiving oxygen therapy. The deficient practice had the potential to increase the probability of R17 to have respiratory difficulties.