A list of the most recent deficiencies for Berry Hill Nursing Home. 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? |
|---|---|---|---|---|
| Provide properly protected cooking facilities. | Fire Safety | 2021-12-20 | 2022-06-10 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-12-20 | 2022-06-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-12-20 | 2022-02-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-12-20 | 2022-02-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-12-20 | 2022-02-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-12-20 | 2022-02-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-12-20 | 2022-02-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-20 | 2022-02-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-20 | 2022-02-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-16 | 2022-01-30 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-12-16 | 2022-01-30 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-12-16 | 2022-01-30 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-12-16 | 2022-01-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-16 | 2022-01-30 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-12-16 | 2022-01-30 | 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 | 2021-12-16 | 2022-01-30 | N |
| Provide activities to meet all resident's needs. | Health | 2021-12-16 | 2022-01-30 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2021-12-16 | 2022-01-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-16 | 2022-01-30 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-12-16 | 2022-01-30 | N |
| Post nurse staffing information every day. | Health | 2021-12-16 | 2022-01-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-12-16 | 2022-01-30 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2021-12-16 | 2022-01-30 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-12-16 | 2022-01-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-16 | 2022-01-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-16 | 2022-01-30 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-12-16 | 2022-01-30 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-12-16 | 2022-01-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-12-16 | 2022-01-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-16 | 2022-01-30 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-12-16 | 2022-01-30 | Y |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2020-01-23 | 2020-03-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-23 | 2020-03-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-09 | 2020-02-11 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2020-01-09 | 2020-02-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-09 | 2020-02-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-09 | 2020-02-11 | 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 | 2020-01-09 | 2020-02-11 | 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 | 2020-01-09 | 2020-02-11 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2020-01-09 | 2020-02-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-09 | 2020-02-11 | N |
| Keep all essential equipment working safely. | Health | 2020-01-09 | 2020-02-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-26 | 2019-01-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-11-26 | 2019-01-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-11-26 | 2019-01-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-11-26 | 2019-01-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-11-08 | 2018-12-23 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2018-11-08 | 2018-12-23 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-11-08 | 2018-12-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-11-08 | 2018-12-23 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-11-08 | 2018-12-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-08 | 2018-12-23 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-11-08 | 2018-12-23 | N |
| Provide activities to meet all resident's needs. | Health | 2018-11-08 | 2018-12-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-08 | 2018-12-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-11-08 | 2018-12-23 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2018-11-08 | 2018-12-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-11-08 | 2018-12-23 | 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 | 2018-11-08 | 2018-12-23 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-11-08 | 2018-12-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-08 | 2018-12-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-08 | 2018-12-23 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-11-08 | 2018-12-23 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2018-11-08 | 2018-12-23 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-11-08 | 2018-12-23 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-11-08 | 2018-12-23 | N |
| Develop a communication plan. | Fire Safety | 2018-11-08 | 2018-12-23 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-11-08 | 2018-12-23 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-11-08 | 2018-12-23 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-11-08 | 2018-12-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-11-08 | 2018-12-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-11-08 | 2018-12-23 | N |
