Berthoud Care and Rehabilitation

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Smoke Deficiencies

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Nursing and Physician Services Deficiencies

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.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Nutrition and Dietary Deficiencies

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

*** CITATION TEXT NOT FOUND *** A revisit to the 9/10/2024 survey was completed on 11/07/2024. No deficiencies were cited. No response is needed.

42 CFR 483.90(a) K3 BUILDING: 0101K6 PLAN APPROVAL: 1961K7 SURVEY UNDER: 2012 Existing K8 SNF/NFType of Structure: A one (1) story with partial basement, 1961, Type V (111), protected combustible construction. The building has complete coverage by an automatic (wet) sprinkler system and a total of six (6) smoke compartments. The facility has a one (1) story with partial basement, 1996, East Building Addition of the same construction type. A Comparative Federal Monitoring Survey was conducted on 9/10/24,.. 42 CFR 483.90(a) K3 BUILDING: 0101K6 PLAN APPROVAL: 1961K7 SURVEY UNDER: 2012 ExistingK8 SNF/NF Type of Structure: A one (1) story with partial basement, 1961, Type V (111), protected combustible construction with a one (1) story with partial basement. The building has complete coverage by an automatic (wet) sprinkler system and a total of six (6) smoke compartments. The facility has a one (1) story with partial basement, 1996, East Building Addition of the same construction type. &nbs.. Based on observation and interview, the facility failed to post signage at oxygen transfilling rooms in compliance with the code. The deficient practice affected one (1) of six (6) smoke compartments, staff, and three (3) residents. The facility had the capacity for 76 beds with a census of 68 on the day of survey.The findings include:Observation during a tour of the building, on 9/10/24, at 12:28 p.m., revealed the liquid oxygen storage room, which was utilized for transfilling and was located near the main dining room. The transfilling room did not ha.. Based on record review and interview, the facility failed to maintain the sprinkler system in accordance with the code. The deficient practice affected six (6) of six (6) smoke compartments, staff, and all residents. The facility had the capacity for 76 beds with a census of 68 on the day of survey.The findings include:Record review, on 9/10/24, at 1:33 p.m., revealed the facility did not have documentation of a quarterly sprinkler system inspection being performed for the first quarter of 2024. The facility failed to perform quarterly sprinkler system inspect.. Based on records review and interview, the facility failed to inspect and test the kitchen hood extinguishing system in accordance with the code. The deficient practice affected one (1) of six (6) smoke compartments, staff, and no residents. The facility had a capacity for 76 beds with a census of 68 on the day of the survey. The findings include:Records review, on 9/10/24, at 1:36 p.m., of the kitchen hood extinguishing system inspection, testing, and maintenance records dating back 12 months prior to the survey revealed the facility did not have any do.. Based on records review and interview, the facility failed to properly inspect and test all components of the emergency generator. The deficient practice affected six (6) of six (6) smoke compartments, staff, and all residents. The facility had a capacity for 76 beds with a census of 68 on the day of the survey. & nbsp; & nbsp; .. Berthoud Care and Rehabilitation was found to be in compliance with Title 42, Code of Federal Regulations, 483.73 et seq. (Emergency Preparedness).

Based on a record review, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1. Missing two (2) year smoke detector sensitivity report.NFPA 101 19.3.4.1 to comply with section 9.6. Section 9.6.1.3, fire alarm system testing and maint.. Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. 1. Delayed egress by the HR office does work NFPA 101, 7.2.1.6.1.1 A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less.. Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. 1. Means of egress shall be created in the patio area. All interior exit doors point to the exit through the patio, which has no exit.2. Exterior exi.. Based on observation and staff interviews, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code Section NFPA 105Records were not available at the time of the survey to document the inspection and testing operation of the fire dampers installed in the facility as required one year after the initial .. Based on observation during the survey, it was determined that the facility failed to have fire extinguishers in accordance with NFPA 10, 6.1.3.1. The fire extinguisher on the patio exceeds the maximum travel distance of 75ft. 6.2.1.1 Minimal sizes of fire extinguishers for the listed grades of hazards shall be provided on the basis of Tab.. Based on observation, it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96. 1.Semi Annual Hood Inspection | Only 04/10/2024 report available for review | no previous report availableNFPA 96 11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a .. Based on observations and records review, it was determined that the facility did not have out-of-service guidance for the fire alarm in accordance with NFPA 101. Out of Service Fire Alarm Guidance | Does not include verbiage for state notificationNFPA 101 9.6.1.6* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour.. Based on observations and records review, it was determined that the facility did not have Sprinkler System out-of-service guidance in accordance with NFPA 101 and NFPA 25Out of service Sprinkler Guidance | Does not include verbiage for state notificationNFPA 101, 9.7.6 Sprinkler impairment procedures shall comply with NFPA 25, Standard .. Based on the documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:No written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding bla.. Based on the record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6Fire drills closer than an hour apart, not at varied timesNFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and admi.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and represent the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The facility is one story, Type V(111) (VA), construction. The facility is protected by a National Fire Protection Association (NFPA) 13 au.. Through observation during the documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13.1. Storage therapy, medical records room, activities storage, and Laundry storage shall be 18" below the fire sprinkler.2. The boiler room has a chain on the fireline that ..

A recertification survey with complaint #CO36268 was completed on 6/5/24 to 6/11/24. Two deficiencies were cited. An Emergency Preparedness survey was conducted from 6/5/24 to 6/11/24. No deficiencies were cited. Based on observations, record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two (#2 and #5) of five residents reviewed for edema care out of 30 sample residents.Specifically, the facility failed to:-Ensure physician orders were followed for the application and removal of elastic hose stockings (used to increase circulation, to prevent blood clots and reduce swelling) for Resident #2; and,-Ensure complete documentation of Resident #5' s edema was completed accurately per physician order for Resident #5. Findings include:I. Facility policyThe Edema Monitoring policy, undated, was provided by the nursing home administrator (NHA) on 6/10/24 at 9:00 a.m. It read in pertinent part "Put on elastic hose as ordered, apply while in bed."II. Resident #2A. Resident statusResident #2, age 75, was admitted on 8/23/21. According to the June 2024 computerized physician orders (CPO), diagnoses included respiratory failure, diabetes, heart failure.. Based on observations, record review and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to:-Ensure the laundry area was free from multiple environmental and sanitary concerns; and,-Ensure clean and dirty storage were maintained in separate locations.Findings include:I. Facility policy and procedureThe Infection Control for Housekeeping Services policy, revised January 2009, was provided by the nursing home administrator (NHA) on 6/11/24 at 9:10 a.m. It read in pertinent part,"It is the policy of this facility to require effective environmental sanitation to lessen the hazards of exposure to contaminated air, dust, furnishings, equipment and other fomites. Equipment shall be maintained in a safe, sanitary condition. Periodic inspection of the facility will be made by the housekeeping supervisor or as a joint exercise with the infection control team."II. Laundry observations and interview..