Berlin Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Berlin Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 27, 2023

  Based on review of facility investigation documentation and medical records; interviews and observations, it was determined the facility failed to have an effective system in place to prevent residents with cognitive impairment from leaving the facility (Resident #41) and failed to supervise a resident outside who had been assessed to be an elopement risk (Resident #4). This failure lead to Resident #41 eloping from the facility on 8/16/23 and Resident #4 self- propelling down the facility driveway on 8/26/22 causing the Resident harm. […]

• Actual harm, isolatedF689Aug 18, 2026

  Based on record reviews, observations and interviews it was determined that the facility failed to 1) ensure residents were free of accidents, and 2) provide adequate supervision to prevent falls. This was found to be evident for 1 (Resident #82) out of 3 Residents reviewed for accidents during the recertification and complaint survey. This deficient practice resulted in actual harm to Resident #82. The findings include: Tracheostomy (trach) - a surgical opening made through the front of the neck to help a person breathe when their regular airway is blocked, damaged, or they require long term breathing machine support. […]

• Actual harm, isolatedF760Jul 23, 2025

  Based on record reviews and interviews it was determined that the facility failed to ensure medications were administered as ordered. This was found to be evident for 1 (Resident #102) out of 1 Resident reviewed for a significant medication error during the re-certification survey. This deficient practice resulted in an actual harm cited as past compliance. The findings include: On 07/20/25 at 5:32 PM a review of the Facility Reported Incident (FRI) #348424 revealed a report that advised Resident #102 was mistakenly administered all of Resident #115's morning medications. As a result, the Resident experienced a significant adverse event and was admitted to the local hospital's Intensive Care Unit (ICU) for treatment. […]

• Actual harm, isolatedF686Sep 27, 2023

  Based on a review of complaints MD00196300, MD00194233, facility-reported incidents MD00196345, MD00193981, hospital records, medical record, facility documentation and interviews, it was determined the facility failed to protect a vulnerable resident ' s skin from injury resulting in harm to Resident #44, and failed to put measures in place to prevent further skin breakdown (Resident #38, #39, #23, #13). This was evident for 5 ( #44, #38, #39, #23, #13) of 43 residents reviewed during a complaint survey. The findings include: 1.) On 9/14/23 at 12:30 PM a review of facility-reported incident MD00196345 revealed that Resident #44 obtained a wound under the trach collar that was located on the back of the neck. […]

• No harm, potential for more than minimal, widespreadF812Jul 23, 2025

  Based on observation and staff interview, it was determined that the facility failed to store and label food items to maintain the integrity of the specific items. This was evident during the initial tour of the kitchen. This deficient practice has the potential to affect all residents. The findings include: On 7/17/2025, at 8:21 AM, during an initial kitchen tour with the Dietary Manager, the surveyor observed three opened, unlabeled bags of bread on a steel cart located in the corner of the room. The Dietary Manager confirmed that opened bags of bread were expected to be labeled. Further observations in the kitchen revealed three 14-ounce containers of Beef flavored base that were unlabeled and located on a cart with other seasonings. […]