Premier Rehab and Healthcare at Berlin

In the surveyor’s words

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

• Immediate jeopardy, isolatedF686May 8, 2025

  Based on interviews and record review, the facility failed to ensure that 3 of 7 residents in the applicable sample (Resident #1, #2, and #3) received necessary treatment and services consistent with professional standards of practice to prevent or promote healing and prevent infection of a pressure injury. As a result, Resident #1 developed an unstageable pressure injury which became necrotic (death of tissue); requiring hospitalization, and resulted in death related to due to osteomyelitis and sepsis of the pressure injury. This citation is at the immediate jeopardy level due to the facility's failure to prevent and treat pressure injury resulting in infection and death of 1 resident. Findings include: 1. […]

• Actual harm, isolatedF760Aug 19, 2024

  Based on interview and record review, the facility failed to ensure 1 out of 5 sampled residents (Resident #16) was free from significant medication errors related to the administration of medication by the wrong route, causing pain and requiring medical attention to Resident #16's eyes. Findings include: Per record review, Resident #16 was admitted to the facility with diagnoses that include, dry eyes, Pseudophakia OU (artificial lens in both eyes) and mild retinopathy (damage to the small vessels in the eye as defined by the American Academy of Opthahalmolgy, 2024). During an interview with Resident #16 on 08/06/2024 at 2:00 PM s/he stated that they received drops for his/her ears to both of his/her eyes. Resident #16 stated It hurt like hell and burned. […]

• Actual harm, isolatedF770Feb 1, 2024

  Based on interview and record review, the facility failed to obtain laboratory services to meet the needs of its residents for 2 of 2 sampled residents (Residents #1 and #2) related to obtaining urinalyses (UA) and culture and sensitivity [C&S; a test to determine if there is an infection, what germ is causing the infection, and what medication will work best to treat the infection] as requested by medical providers in a timely manner. As a result, Resident #1 and #2 suffered symptoms of urinary tract infections (UTI), a disease that can be diagnosed with a urinalysis and C&S, and were both transferred to the emergency department (ED) with sepsis [a life-threatening complication of an infection] caused by a UTI. Findings include: 1. […]

• Actual harm, isolatedF776Feb 1, 2024

  Based on interview and record review, the facility failed to obtain an EKG (electrocardiogram; a diagnostic test to evaluate heart function) to meet the needs of its residents for 1 applicable resident (Resident #2). As a result, Resident #2 was transferred to the Emergency Department (ED) and later to the ICU (intensive care unit) to manage the cardiac complications including atrial fibrillation (irregular, often rapid heart rate) with RVR (rapid ventricular response; abnormal rhythm originating in the lower chambers of the heart) and NSTEMI Type II (a heart attack due to mismatched oxygen supply and demand to the heart muscle), both cardiac conditions can potentially be diagnosed with an EKG. […]

• Actual harm, isolatedF635Jul 27, 2023

  Based on staff interview and record review, the facility failed to obtain accurate physician orders to provide necessary care and services on admission for 3 of 3 applicable residents (Residents #1, #2, and #3). Findings include: Facility policy Standards and Procedures for All Licensed Independent Practitioners, revised 9/17/21, states, Upon the admission of a patient, the attending physician or advanced practice provider (APP) is required to: Enter appropriate admission orders on the day of admission. […]