Berea Center

In the surveyor’s words

From the most serious findings on record at Berea Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jun 1, 2023

  Based on observation and interview, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all 47 residents residing in the facility. Findings included: Tour of the kitchen on 05/30/23 from 8:56 A.M. through 9:15 A.M. with Dietary Manager (DM) #857 revealed the wall where the prep table that housed the microwave had various dried splatters and red streaks running down the wall at the point of the middle shelf toward the floor. Next to the microwave was the knife holder that had various stains and debris. Observed DM #857 pickup the knife holder and underneath were various food debris and a butter knife. The commercial can opener holder had dark brownish black build up. Also on the prep table was a toaster that had various splatters and stains. […]

• No harm, potential for more than minimal, patternF550Feb 2, 2023

  Based on record review, staff interview, review of facility Self-Reported Incident (SRIs), and review of the policy titled OHIO Abuse, Neglect, and Misappropriation the facility failed to monitor resident-to-resident interactions that may limit residents' autonomy or choice. This affected four (#6, #47, #48, and #50) of four residents reviewed for sexual abuse. The facility census was 48. Findings include: 1. Review of the medical record for Resident #6 revealed an admitted [DATE]. […]

• No harm, potential for more than minimal, isolatedF657Jul 31, 2026

  Based on interview, record review, and facility policy review, the facility failed to ensure a care plan was updated to reflect the need and implementation of a therapy-ordered lipped plate for one resident (#4) of three sampled residents reviewed for assistive device use. Findings included:Record review revealed an admission Record that identified the facility admitted Resident #4 on 07/30/25. According to the admission Record, the resident had a medical history that included diagnoses of vascular dementia and mild protein-calorie malnutrition. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/09/2026, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. […]

• No harm, potential for more than minimal, isolatedF759Jul 31, 2026

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure the medication error rate was 5% or less. There were two errors out of 27 opportunities, which yielded a medication error rate of 7.41%. This affected one resident (#26) of two residents observed for medication administration. Findings included: Review of an admission Record indicated the facility admitted Resident #26 on 05/25/2024. According to the admission Record, the resident had a medical history that included a diagnosis of Alzheimer's disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/25/2026, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. […]

• No harm, potential for more than minimal, isolatedF810Jul 31, 2026

  Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure a therapy-ordered lipped plate was used at breakfast and lunch. This affected one resident (#4) of three sampled residents reviewed for assistive device use.Findings included:Review of an admission Record revealed the facility admitted Resident #4 on 07/30/2025. According to the admission Record, the resident had a medical history that included diagnoses of vascular dementia and mild protein-calorie malnutrition. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/09/2026, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. […]