Berea Health & Rehab Center

In the surveyor’s words

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

• Actual harm, isolatedF580Jun 2, 2023

  Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to immediately notify the physician of a significant change in condition for one of 34 residents, Resident #65, which constituted harm. The findings include: For Resident #65, the facility staff failed to immediately notify the physician of a significant change in oxygen saturation. Your blood oxygen level (blood oxygen saturation) is the amount of oxygen you have circulating in your blood (1). […]

• Actual harm, isolatedF658Jun 2, 2023

  Based on resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to follow professional standards of quality for two of 34 residents in the survey sample, Resident #18 and Resident #65, which resulted in harm for Resident #65. The findings include: 1. The facility staff, registered nurse (RN #2), failed to ensure oxygen was administered at an acceptable rate for Resident #65, who had a diagnosis of COPD (chronic obstructive pulmonary disease); and, failed to call the physician and/or 911 immediately, when the resident had a significant change in condition. […]

• Actual harm, isolatedF689Jun 2, 2023

  Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide the proper assistance while providing ADL (activities of daily living) care which resulted in a fall from the bed for one of 34 residents in the survey sample, Resident #219. The resident sustained a right leg fracture which constituted harm cited at past non-compliance. The findings include: For Resident #219 (R219), the facility staff failed to implement the plan of care while providing ADL care which resulted in the resident falling from the bed and suffering a fractured right tibia and fibula (1). […]

• No harm, potential for more than minimal, widespreadF812Mar 5, 2026

  Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to store food, in one of one kitchens, in a sanitary manner.The findings include:On 3/3/26 at 12:00 PM, an observation was conducted in the kitchen with the following findings: in the walk-in refrigerator, observation of a two-gallon zip lock bag unsealed with fish dated 3/2/26. The cook sealed the zip lock bag. The cook stated, the bag should be completely sealed, it was not, our standard is to have refrigerated food in sealed containers.On 3/4/26 at 5:00 PM, the Administrator and the Director of Nursing were informed of the above concerns.A review of the facility's Storage of Refrigerated Foods policy revealed, Store all food/leftovers in covered, approved, food grade… […]

• No harm, potential for more than minimal, widespreadF727Jan 12, 2022

  Based on staff interview and facility document review, it was determined the facility staff failed to maintain RN (registered nurse) coverage for eight hours a day for every day. The findings include: Review of the as - worked schedules for the past 30 days was conducted. Review of the December schedules revealed, there was no RN coverage on the following days: 12/12/2021 and 12/26/2021. On 12/25/2021, there was only four hours of RN coverage. Review of the January schedules revealed, there was no RN coverage on the following days: 1/2/2022, and 1/8/2022. An interview was conducted with ASM (administrative staff member) #2, the acting director of nursing, on 1/12/2022 at 10:36 a.m. The schedules above were reviewed with ASM #2. […]