Berea Health and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF655Jul 27, 2024

  Based on interview, record review, and review of the facility's policy, the facility failed to develop and implement a baseline care plan to provide effective and person-centered care of residents and meet professional standards of care for 1 of 5 sampled residents (Resident (R))1. The facility admitted R1 on [DATE] at 11:30 AM, with a diagnosis of lumbar vertebra fracture. R1's Physician's Orders included supplemental oxygen (O2) at five liters per minute (5 LPM) per nasal cannula (nc) continuously. However, the facility failed to develop and implement a baseline care plan with detailed interventions related to R1's Physician's Order for supplemental O2 per nc at 5 LPM. […]

• Immediate jeopardy, isolatedF695Jul 27, 2024

  Based on interview, record review, and review of the facility's policy, the facility failed to ensure a resident who needed respiratory care was provided consistent with professional standards of practice for one (1) of five (5) sampled residents (Resident (R) 1). The facility admitted R1 on [DATE], for rehabilitation after sustaining a spinal fracture. R1 was noted to have a Physician's Order dated [DATE], for oxygen at five liters per minute (5 LPM) continuously. However, R1 was sent back to the hospital on [DATE] at 12:25 AM, due to low oxygen saturation (O2 sat) level of 41% while on 2 LPM oxygen (not the ordered 5 LPM) per a nasal cannula (nc). […]

• No harm, potential for more than minimal, patternF880Apr 9, 2026

  Based on observation, interview, record review, and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, which had the potential to affect 30 of 30 sampled residents, and other facility residents.The findings include: Review of the facility policy titled, Infection Prevention and Control Program, revised 08/20/2025, revealed the facility infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. […]

• No harm, potential for more than minimal, patternF689Jan 12, 2021

  Based on observation, interview and record review it was determined the facility failed to ensure the resident's environment remained as free from accident hazards as is possible related to the use of air mattresses for three (3) of three (3) sampled residents who utilized air mattresses, (Resident #2, Resident #6 and Resident #7), out of a total of eight (8) sampled residents. Interviews and record review revealed staff placed an air mattress on Resident #2's bed on 12/23/2020, to facilitate wound healing. The resident's record revealed he/she had a fall from the bed on 12/28/2020, and review of the facility fall investigation indicated staff determined the resident's air mattress, with no bolsters, was the causative factor of the resident's fall. […]

• No harm, potential for more than minimal, isolatedF755Apr 9, 2026

  Based on interview, and review of facility documents and policy, the facility failed to establish a system to ensure thorough accounting of the disposition of all controlled drugs to enable accurate reconciliation of those drugs, which had the potential to affect residents on narcotic medications out of the 30 sampled residents. The findings include: Review of the facility policy titled, Controlled Medication, dated 08/13/2024, revealed controlled drugs were to be counted at each shift by two staff members who were licensed nurses, medication technicians, or appropriate staff per state regulations. Continued review revealed the controlled drug counts were to be documented on the controlled medications accountability record. […]