Bertha D Garten Ketcham Memorial Center

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and visitors for 9 of 9 rooms tested for hot water. The water temperatures were above 120 degrees. (room [ROOM NUMBER], room [ROOM NUMBER]/38, room [ROOM NUMBER], room [ROOM NUMBER]/34, room [ROOM NUMBER]/24, room [ROOM NUMBER]/26, room [ROOM NUMBER]/36, room [ROOM NUMBER]/12, room [ROOM NUMBER]/16).

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the correct resident representative of changes for 1 of 2 residents reviewed for guardianship. A resident deemed by the court to be incompetent, was appointed a guardian (resident's father) but the facility was contacting the father's wife (resident's stepmother) instead. (Resident 6)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received necessary respiratory care and services in accordance with professional standards of practice for 2 of 5 residents reviewed for respiratory care. The filters on the oxygen concentrators were dusty. (Resident 27, Resident 9)

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan included pertinent information regarding a newly admitted resident's health care needs for 1 of 2 residents reviewed for ostomy care. The baseline care plan included no mention of a newly acquired colostomy. (Resident B)

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent falls for 2 of 3 residents reviewed for accidents. Following falls, resident care plans were not updated with interventions to prevent further falls, and a resident's environment was not free of hazards, which resulted in a fall and leg fracture. (Resident C, Resident D)

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person centered comprehensive care plan for 3 of 5 residents reviewed for unnecessary medications and 1 of 2 residents reviewed for accidents. Resident's who were on an antiplatelet medication, a diuretic medication, EBP (Enhanced Barrier Precautions), contact isolation, and a fall did not have care plans developed or revised. (Resident 16, Resident 36, Resident 20)

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were labeled in accordance with currently accepted professional principles and the expiration date for 3 of 4 medication carts observed for medication storage and medications for multiple residents' morning medication pass were stored in medication cups with their names on them in the top left drawer of the medication cart for 1 of 4 medication carts observed during medication pass. (Medication Cart 3 on East Hall in the main building, Medication Cart in [NAME] House, Medication Cart in [NAME] House)

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure food was stored and prepared safely in accordance with professional standards for food service for 2 of 2 kitchen observations. Foods were not labeled correctly and a used cooking utensil was dropped into the food to be served. Temperature and dishwasher logs were not filled out daily. (Daisy House, [NAME] House)

Inspectors wroteBased on interview and record review, the facility failed to notify and consult the physician, resident, and/or resident's representative of changes that may require an alteration in the resident's care for 2 of 5 residents reviewed for unnecessary medications. The physician, resident, and/or resident's representative were not notified of a resident's missed medication dose and a resident's weight loss. (Resident 4, Resident 15)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision and assistance devices were provided to prevent accidents for 1 of 2 residents reviewed for falls. A resident's care plan was not updated timely with a new intervention after her first fall and the resident fell again with the intervention not being in place at the time of the fall. (Resident 15)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receiving psychotropic medications were assessed for continued use of the medication for 1 of 5 residents reviewed for unnecessary medications. A resident's antipsychotic medication was not decreased timely as recommended, and was increased with no indication. (Resident 15)

Inspectors wroteBased on observation and interview, the facility failed to ensure a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Staff did not change gloves or perform hand hygiene during resident care for 1 of 2 residents observed for care. A medication was touched with bare hands for 1 of 8 observations of medication administration, and staff did not perform hand hygiene before or after administering medications. (Resident 39, Resident 22)

Inspectors wroteBased on observation and interview, the facility failed to post the nurse staffing data sheet on a daily basis at the beginning of each shift for 2 of 5 days (10/3/24, 10/7/24) reviewed for posted nurse staffing data sheet posting. (Main Building and [NAME] House)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident assessments were completed and updates to the plan of care were made following wandering and exit seeking behaviors for 2 of 3 residents reviewed for dementia care and elopement. No post elopement risk assessment was completed after a resident residing on a locked dementia unit pushed an exit door open to exit the facility and two residents with documented exit-seeking and/or wandering behaviors had no plan of care with interventions to address the behavior. (Resident B, Resident C)

Inspectors wroteBased on observation and interview, the facility failed to ensure proper storage of medications in 1 of 3 medication storage rooms and 2 of 5 medication carts. Narcotic boxes were not locked in the medication carts. Temperatures were not checked daily on a refrigerator storing resident immunizations and medications. Discontinued medications were stored in the storage rooms and not appropriately disposed. (West Hall)

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received physician ordered medications upon admission. A resident's medication was not continued after admission for 1 of 2 closed records reviewed. (Resident B)

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately complete MDS (minimum data set) Assessments for 1 of 1 residents reviewed for Resident Assessment. (Resident 28)