Berry Hill Nursing Home

In the surveyor’s words

From the most serious findings on record at Berry Hill Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF576Dec 16, 2021

  Based on group interview, staff interview, and facility document review, the facility staff failed to ensure mail delivery to residents. Findings include: On 12/15/21 beginning at 3:00 p.m. a group interview was conducted with eleven cognitive residents (Residents # 18, 5, 24, 30, 22, 32, 36, 49, 31, 158, and 11). The group was asked about mail delivery in the facility, and if mail was received on Saturdays and also received unopened. The group responded No. Resident # 11 stated We haven't gotten any mail since the activity director left over a month ago. You know, it's close to Christmas, and we don't even know if we have gotten cards or anything. On 12/15/21 at approximately 4:30 p.m. the administrator was asked about the mail delivery, and for a policy. […]

• No harm, potential for more than minimal, widespreadF835Dec 16, 2021

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide effective administration in a manner to maintain the highest practicable well-being of each resident. The facility staff failed to employ staff in the following key positions: activities director and infection control preventionist; and failed to have a restorative program in place. The findings include: An onsite survey was conducted from 12/14/2021 through 12/16/2021. During the survey deficient practice was identified in the areas of residents rights and activities including F550, F565, F576, F679, and F680 which were related to the facility not employing an activities director since 11/5/2021. […]

• No harm, potential for more than minimal, widespreadF880Dec 16, 2021

  Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow infection control policies for hand hygiene during a medication pass observation, failed to provide an ongoing program of infection surveillance, and failed to follow infection protocols for PPE (personal protective equipment) use for one of seventeen residents in the survey sample, Resident #34. The findings include: 1. A medication pass observation was conducted on 12/14/21 at 4:32 p.m. with licensed practical nurse (LPN #2) administering medications to three residents. LPN #2 prepared medications and administered them to Resident #15. Oral medications were administered in addition to nasal spray, [MEDICATION(S)] diskus aerosol inhaler, and eye drops. […]

• No harm, potential for more than minimal, widespreadF881Dec 16, 2021

  Based on staff interview and facility document review, the facility staff failed to implement an antibiotic stewardship program for the facility. The findings include: There was no staff person designated as the infection preventionist during the current survey. On 12/15/21 at 2:00 p.m., the administrator stated the facility had not had a designated/qualified infection preventionist since 9/8/21. The administrator stated the registered nurse staff development coordinator (RN #1) would assist with review of the infection control program. The infection control program was reviewed on 12/16/21 and revealed no evidence of an antibiotic stewardship program. Infection tracking information was missing for January 2021 and February 2021. […]

• No harm, potential for more than minimal, widespreadF882Dec 16, 2021

  Based on staff interview and facility document review, the facility staff failed to designate a qualified infection preventionist for the facility. The findings include: On 12/15/21 at 2:00 p.m., the administrator was interviewed about the facility's designated infection preventionist. The administrator stated they currently had no staff person qualified and/or trained to be the infection preventionist. The administrator stated the previous infection preventionist was out of leave during August 2021, resigned and did not work after 9/8/21. The administrator stated they had not had an infection preventionist since 9/8/21. On 12/15/21 at 2:52 p.m., the regional nurse consultant (administration staff #3) was interviewed about an infection preventionist for the facility. […]