Bertha D Garten Ketcham Memorial Center

In the surveyor’s words

From the most serious findings on record at Bertha D Garten Ketcham Memorial Center, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 26, 2025

  Based 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) Findings include: 1. Record review for Resident C was completed on 2/26/25 at 11:15 A.M., Resident C's diagnoses included, but were not limited to, fracture of lower end right femur, cellulitis of left lower limb, type II diabetes, morbid obesity, muscle weakness, need for assistance with personal care, and overactive bladder. […]

• No harm, potential for more than minimal, patternF921Jan 22, 2026

  Based 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).Findings include: 1.On 1/15/2026 at 10:44 A.M., the water temperature in the bathroom of room [ROOM NUMBER] (private room) was 126.8 degrees Fahrenheit.2. On 1/15/2026 at 10:50 A.M., the water temperature in the bathroom between Rooms 37/38 (bathroom shared with four residents) was 125.7 degrees Fahrenheit. […]

• No harm, potential for more than minimal, patternF656Oct 10, 2024

  Based 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) Findings include: 1. On 10/8/24 at 4:37 P.M., Resident 16's clinical record was reviewed. Diagnoses included, but were not limited to, Atrial Fibrillation, hypertension, and coronary artery disease. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 7/4/24 indicated Resident 16 received a diuretic medication. […]

• No harm, potential for more than minimal, patternF761Oct 10, 2024

  Based 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) Finding includes: 1. […]

• No harm, potential for more than minimal, patternF812Oct 10, 2024

  Based 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) Findings include: 1. On 10/3/24 at 10:26 A.M., the following was observed in the [NAME] House kitchen refrigerators: tomatoes in a Tupperware bowl-- undated and unlabeled 112 oz (ounce) can of milk chocolate pudding-- undated, unlabeled, and open to air 2. […]