A list of the most recent deficiencies for Berkley West Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-02-02 | 2024-03-01 | Y |
| Assess the resident when there is a significant change in condition | Health | 2024-02-02 | 2024-03-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-02 | 2024-03-01 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-02-02 | 2024-03-01 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-02-02 | 2024-03-01 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-02-02 | 2024-03-01 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-12-21 | 2024-01-11 | Y |
| Keep all essential equipment working safely. | Health | 2023-12-21 | 2024-01-11 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-10-23 | 2023-11-22 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-10-23 | 2023-11-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-10-23 | 2023-11-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-23 | 2023-11-18 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-10-16 | 2023-11-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-16 | 2023-11-11 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-10-16 | 2023-11-11 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-10-16 | 2023-11-11 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-10-16 | 2023-11-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-16 | 2023-11-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-16 | 2023-11-11 | N |
| Provide appropriate foot care. | Health | 2023-10-16 | 2023-11-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-16 | 2023-11-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-16 | 2023-11-11 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-16 | 2023-11-11 | N |
| Post nurse staffing information every day. | Health | 2023-10-16 | 2023-11-11 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-10-16 | 2023-11-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-10-16 | 2023-11-11 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-10-16 | 2023-11-11 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-10-16 | 2023-11-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-16 | 2023-11-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-16 | 2023-11-11 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-09 | 2023-07-08 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-06-09 | 2023-07-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-24 | 2023-06-22 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-05-24 | 2023-06-22 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-10 | 2023-06-08 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-05-10 | 2023-06-08 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-26 | 2023-05-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-25 | 2023-05-19 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-25 | 2023-05-19 | Y |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2022-10-25 | 2022-12-15 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-10-25 | 2022-12-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-25 | 2022-12-15 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-10-25 | 2022-12-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-10-25 | 2022-12-15 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-10-25 | 2022-12-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-25 | 2022-12-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-10-25 | 2022-12-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-25 | 2022-12-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-10-25 | 2022-12-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-25 | 2022-12-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-25 | 2022-12-15 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-10-23 | 2022-11-22 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-10-23 | 2022-11-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-10-23 | 2022-11-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-23 | 2022-11-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-10-23 | 2022-11-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-23 | 2022-11-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-23 | 2022-11-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-23 | 2022-11-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-23 | 2022-11-22 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-10-23 | 2022-11-22 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-10-23 | 2022-11-22 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-10-23 | 2022-11-22 | N |
| Post nurse staffing information every day. | Health | 2022-10-23 | 2022-11-22 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-10-23 | 2022-11-22 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-10-23 | 2022-11-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-23 | 2022-11-22 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-10-23 | 2022-11-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-23 | 2022-11-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-23 | 2022-11-22 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-10-23 | 2022-11-22 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-10-23 | 2022-11-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-14 | 2022-10-04 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-03-11 | 2022-03-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-28 | 2021-09-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-05 | 2021-07-13 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-24 | 2019-05-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-24 | 2019-05-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-04-24 | 2019-05-17 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-04-24 | 2019-05-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-04-24 | 2019-05-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-24 | 2019-05-17 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-04-24 | 2019-05-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-24 | 2019-05-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-23 | 2019-05-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-23 | 2019-05-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-09 | Not Fixed | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-09 | Not Fixed | N |
