Berlin Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jul 24, 2026

  Complaint #: 3069904Based on interviews, record reviews, and review of pertinent facility documents on [DATE], it was determined that the facility failed to a) ensure that a cognitively impaired resident (Resident #2) was free from sexual abuse by a Certified Nursing Assistant (CNA #1), and b) implement their abuse policy to ensure all residents were free from sexual abuse. This deficient practice was identified for 1 of 4 residents reviewed for abuse (Resident #2). This resulted in an Immediate Jeopardy (IJ) situation and posed the likelihood of serious harm or injury to all residents.On [DATE], Resident #2's family member reported an allegation to Licensed Practical Nurse (LPN #1) and Social Worker (SW #1) that the resident had been sexually abused. […]

• Immediate jeopardy, isolatedF689Aug 25, 2025

  Based on interviews, review of medical records, and other pertinent facility documentation on [DATE], it was determined that the facility failed to provide adequate supervision to a cognitively impaired resident (Resident #2) with a known history of elopement who eloped from the facility on [DATE]. The deficient practice was identified for 1of 3 residents (Resident #2).The resident had a history of exiting their unit on [DATE]. On [DATE] at approximately 6:01 P.M., Resident #2, while wearing a wander guard (security bracelet), left their unit on the second-floor and exited the facility through the main lobby front door. […]

• Actual harm, isolatedF686Dec 11, 2023

  NJ00166442 Based on interviews, review of closed medical records and other facility documentation, it was determined that the facility failed to consistently implement timely interventions in adherence with the facility pressure injury prevention policy and the resident's care plan to promote skin integrity and prevent the development of moisture-associated skin damage (MASD) of both the right and left buttocks, a deep tissue injury (DTI, an injury of the underlying tissue below the skin's surface that results from prolonged pressure) of the left lateral heel and an unstageable pressure ulcer of the right lateral ankle. This deficient practice was identified for 1 of 2 residents (Resident #172) reviewed for pressure ulcer management. […]

• No harm, potential for more than minimal, widespreadF803May 23, 2025

  Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) the facility's four week cycle menus were consistently nutritionally adequate for fruit, protein, and starch servings in accordance with the facility provided Diet Manual and nationally accredited standards, b.) standardized recipes were readily available and followed, and c.) that all listed menu items were consistently provided at meals (Resident's #1, #28, #44, #81 and #88). This deficient practice was identified by surveyors during meal rounds on 3 of 3 units and was supported by 5 of 5 residents that attended the Resident Council Meeting on 5/20/25 (Resident's #8, #15, #50, #56 and #58). […]

• No harm, potential for more than minimal, patternF880Dec 11, 2023

  Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to maintain proper infection control practices during the a) Medication administration observation and b) Dining observation. This deficient practice was identified on 1 of 3 nursing units (Cherry Unit) and for 1 of 3 nurses (LPN #5) observed during the medication pass. This deficient practice was evidenced by the following: 1. On 12/01/23 at 8:16 AM, the surveyor observed Licensed Practical Nurse (LPN #5) as he prepared and administered medications on the Cherry Unit. LPN #5 first obtained a treatment cart from the other end of the hall and placed it beside the medication cart and stated that he intended to use it for additional work space. […]