Deficiency Records for Bertha D Garten Ketcham Memorial Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Bertha D Garten Ketcham Memorial 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? |
|---|---|---|---|---|
| Address subsistence needs for staff and patients. | Fire Safety | 2023-12-14 | 2024-01-25 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-12-14 | 2024-01-25 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-12-14 | 2024-01-25 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-12-14 | 2024-01-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-14 | 2024-01-25 | N |
| Use approved construction type or materials. | Fire Safety | 2023-12-14 | 2024-01-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-12-14 | 2024-01-25 | 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 | 2023-12-14 | 2024-01-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-14 | 2024-01-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-14 | 2024-01-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-12-14 | 2024-01-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-14 | 2024-01-25 | N |
| Have enough space near smoke barriers to protect residents. | Fire Safety | 2023-12-14 | 2024-01-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-12-14 | 2024-01-25 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-12-14 | 2024-01-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-14 | 2024-01-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-12-14 | 2024-01-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-12-14 | 2024-01-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-04 | 2023-12-29 | 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 | 2023-12-04 | 2023-12-29 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2023-12-04 | 2023-12-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-03 | 2023-08-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-10 | 2023-04-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-10 | 2023-04-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-25 | 2022-09-25 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-31 | 2022-03-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-01-31 | 2022-02-18 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-01-31 | 2022-02-17 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-01-31 | 2022-02-17 | N |
| Develop a communication plan. | Fire Safety | 2022-01-31 | 2022-02-17 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-01-31 | 2022-02-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-31 | 2022-02-17 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-01-06 | 2022-01-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-09 | 2021-09-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-30 | 2021-04-19 | Y |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-12-11 | 2019-12-31 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-12-11 | 2019-12-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-12-11 | 2019-12-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-11 | 2019-12-31 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-09-18 | 2019-10-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-18 | 2019-10-04 | 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 | 2019-09-18 | 2019-10-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-18 | 2019-10-04 | N |
| Post nurse staffing information every day. | Health | 2019-09-18 | 2019-10-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-18 | 2019-10-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-09-18 | 2019-10-04 | N |
