Berkeley Nursing & Rehab Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Dec 20, 2022

  Based on observation, interview and record the facility failed to avoid an accident by not ensuring that the window safety latch was engaged to prevent a window from opening no greater than the 1 ,d+[DATE] inch in height. This failure affects one of three residents (R9) reviewed for accidents. R9 room window observed open at its highest and R9 observed outside on the ground, and unresponsive, R9 subsequently noted cold to touch, with rigor in the jaw and with obvious signs of death, R9 pronounced deceased at 5:49am on [DATE]. This was identified as an immediate jeopardy which began on [DATE] when R9 was found outside the facility on the ground below his room window. […]

• Actual harm, isolatedF684Apr 4, 2025

  Based on interview and record review, the facility failed to follow their change in condition policy by not calling advance life support services (911) for two hours after R48 who was found with an altered mental status and verbally unresponsive. This failure resulted in R48 immediate intubation by emergency medical service and mechanical ventilation for 1 of 1 residents reviewed for change in condition. Findings Include: R48 has the diagnosis of Atrial Fibrillation, Lack of coordination, abnormalities of gait and mobility, need for assistance with personal care and Adult Failure to Thrive. R48's physician order summary dated 2/7/25 documents: Rivaroxaban (antithrombotic/prevent blood clots) fifteen milligrams given by mouth at bedtime for atrial fibrillation. […]

• Actual harm, isolatedF580Sep 6, 2024

  Based on interview and records review, the facility failed to notify the physician of a resident's decrease in blood pressure and decrease in oxygen saturation causing a further decline in condition. This affected one of three residents (R1) reviewed for notification of an acute change in condition. This failure resulted in R1 being sent to the hospital thirteen hours later emergently in respiratory distress, going in to cardiac arrest while in the emergency department, and expiring. Findings Include: R1 is a [AGE] year old with the following diagnosis: quadriplegia, encounter for gastrostomy, and acute respiratory failure. A Nursing note dated [DATE] at 11:32AM documents in the morning, R1 was noted resting in bed and left eye opened to name being called. […]

• Actual harm, isolatedF684Sep 6, 2024

  Based on interview and record review, the facility failed to conduct a comprehensive assessment of a resident after experiencing a decrease in blood pressure and oxygen level and failed to reassess vital signs later in the shift. This affected one of three residents (R1) reviewed for comprehensive nursing assessments. This failure resulted in R1 being sent to the hospital in respiratory distress, going into cardiac arrest in the emergency room , and expiring. Findings Include: R1 is a [AGE] year old with the following diagnosis: quadriplegia, encounter for gastrostomy, and acute respiratory failure. A Nursing note dated [DATE] at 11:32AM documents in the morning, R1 was noted resting in bed and left eye opened to name being called. […]

• Actual harm, isolatedF697May 26, 2023

  Based on observation, interview, and record review, the facility failed to implement effective pain management for one resident's (R139) with severe pain of one resident reviewed for pain in a sample of 12. This failure resulted in R139 becoming extremely anxious in anticipation of pain, crying and saying she wanted to die because the pain was so bad. Findings include: On 05/23/23 at 8:30 AM R139 was observed lying in bed, soft spoken, and V16 (LPN) at bedside. V16 asked how R139 was doing and R139 states her neck hurts. V16 states oh your neck is still hurting. V16 then leaves the room without asking R139 her pain level. R139's [NAME] is to her chest and the resident looks uncomfortable. Surveyor asked R139's pain level from 1-10. R139 states her pain level is 9/10. […]