Berrien Oaks Nursing and Rehab Center

In the surveyor’s words

From the most serious findings on record at Berrien Oaks Nursing and Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF803May 14, 2026

  Based on observations and staff interviews, the facility failed to ensure pureed meals were prepared according to standardized recipes and appropriate consistency requirements for eight of eight residents who received a pureed diet. Specifically, pureed meals were not consistently prepared or served in a manner that maintained appropriate texture, appearance, palatability, and safety for residents with swallowing difficulties. This deficient practice had the potential to affect all residents receiving pureed diets by placing them at risk for choking, aspiration, poor nutritional intake, and decreased quality of life.Findings include:Observation on 05/11/2026 at 11:00 AM of puree preparation revealed that a recipe was not followed. […]

• No harm, potential for more than minimal, widespreadF812May 14, 2026

  Based on observations, staff interviews, and review of the facility policy titled, Food Storage: Cold Food Items, the facility failed to ensure that food was properly labeled and dated and in sanitary conditions to prevent foodborne illness. The deficient practice had the potential to affect 94 residents of 95 who received meals from the kitchen.Findings include:Review of the facility policy titled Food Storage: Cold Food Items revealed under Procedure: . 5. Cold foods are to be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross-contamination.A tour on 05/11/2026 at 9:45 AM with the Dietary Manager revealed the following concerns: Observation of the walk-in refrigerator revealed a bag of finely diced cabbage with carrots, a package of… […]

• No harm, potential for more than minimal, widespreadF812Feb 1, 2024

  Based on observations, staff interviews, and review of the facility's' policies titled, Date Marking for Food Safety and Food Nutrition Sanitation and Food Products, the facility failed to ensure ice was covered and transported in a sanitary manner, food items were properly stored, labeled, and dated, and expired food items disposed of in a timely manner. In addition, the facility failed to follow the manufacture guidelines for proper sanitation procedures with the 3-compartment sink and dishwasher for sanitation of washing cookware and dishes. The dietary equipment was maintained under sanitized conditions free from rust and a pedal push garbage container was accessible to staff. The flooring and walls of the facility were free from dirt and debris. […]

• No harm, potential for more than minimal, widespreadF880Feb 1, 2024

  47948 Based on observations, resident and staff interviews, and review of the facility's policies titled, Oxygen Administration, Medication Administration, Medication Administration: Oral and Nasal Inhalations, Hand Hygiene, COVID-19 Prevention, Response and Reporting, and Water Management Policy the facility failed to ensure infection control measures were followed during the administration of nasal and oral inhalation medications for one of 29 residents (R) (R40), and hand hygiene was performed during medication administration for one of five residents (R40). The facility also failed to decrease the chance of COVID-19 spread by allowing two residents (R68 and R70) to cohort in the same rooms as positive tested COVID-19 residents (R64 and R65). […]

• No harm, potential for more than minimal, patternF584Apr 17, 2025

  Based on observations, resident and staff interviews, and review of the facility's policy titled, Physical Environment-Room Repairs, the facility failed to ensure that resident's rooms were clean and in good repair in two of five halls, in rooms (Rm) Rm 130, Rm 134, Rm 135, Rm 136, and Rm 143, and in the kitchen and laundry. Findings include: Review of the facility's policy titled Physical Environment-Room Repairs effective date 9/26/2023 stated under Policy: The center will ensure the residents have a safe, homelike, environment free from physical hazards. Under Procedure: 1. To ensure a safe, homelike environment. Findings from these rounds will be prioritized and the repairs made as indicated. 2. […]