Berkeley Nursing & Rehab Center

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a comfortable environment, temperature range of 71 degrees F (Fahrenheit) and 81degrees F, for residents during extreme hot weather conditions and failed to achieve relative humidity and temperature ranges outside of the caution level based on the heat index from the National Oceanic Atmospheric Administration chart. These failures had the potential to affect all 61 residents at the facility. The Facility's resident roster dated 6/30/2026, showed there were 61 residents who reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents are free from verbal abuse for one of three residents (R1) reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the Food Safety and Sanitation Policy by dietary staff using gloved hand to directly scoop a piece of cornbread after handling multiple food ladles, and dietary staff observed without beard covering for their exposed beards, and by not ensuring a bag of frozen peaches and open bottle of dried parsley was labeled with a made/open date and expiration date. This failure has the potential to affect all 48 residents in the facility on oral diets.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident with dignity during mealtime. This affected one of three residents (R5) reviewed for dignity. Findings Include: R5 has a diagnosis of Hemiplegia and visual loss. Minimal data set section G (functional abilities) dated 1/10/25 documents: eating - R5 requires partial/moderate assistance. Helper does less than half the effort. Care plan revised on 1/15/25 documents: R5 required extensive assistance times one staff participation to eat. On 4/1/25 at 12:31PM, R5 observed in the main dining room, being fed by V8 (Certified Nursing Assistant/CNA). V8 told R5, she has to feed R5 like baby. On 4/2/25 at 1:09PM, V2 (Director of Nursing/DON) said, staff should not tell any resident they have to feed them like a baby, it is not appropriated, it takes away their dignity. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an appropriate call light and accessibility to a call light for one resident who was identified with self-care deficits. This affected one of three residents (R22) reviewed for call light accessibility. Findings Include: R22 has a diagnosis of Quadriplegia. Minimal Data Set section C (cognitive pattern) dated 3/20/25 documents: a score of fifteen which indicates R22 is cognitively intact. Section GG (functional abilities) documents: impairment on both sides for upper and lower extremities. Dependent on staff. Care plan initiated 9/29/2020 documents: R22 has activities of daily living self-care performance deficit related contractures bilateral upper/lower extremities, Quadriplegia. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide incontinence care at least every two hours. This affected one of three residents (R5) reviewed for incontinence care. Finding Including: R5 has a diagnosis of Hemiplegia. Minimal data set section G (functional abilities) dated 1/10/25 documents: Toileting hygiene: dependent. Section H (bladder and Bowel) documents: Urinary Continence: R5 was always incontinent. Care plan initiated 4/2/22 documents: R5 is incontinent of bladder and bowel function related to impaired mobility, weakness and other co-morbidities secondary to diagnosis of: hemiplegia, affecting left non-dominant side. Goal: staff will assist with toileting throughout the day. On 4/1/25 at 1:09pm, R5 was observed sitting in his wheelchair with wet soiled pants in his peri-area/between his legs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders by not applying splint or braces for three residents (R5, R11 and R19) out of three residents reviewed for restoratives services.

Inspectors wroteBased 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. Medication administration record dated 2/1/25-2/28/25 and 3/1/25 documents: R48 received Rivaroxaban as prescribed. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. At 11:20AM, V3 (Former Nurse) found R1 diaphoretic with cool/clammy skin, respiratory rate of 60 breaths per minute, and a heart rate of 96 beats per minute. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to display in a public and accessible location, the [NAME] and [NAME] Retaliation Hotline poster informing residents of their right to explore or decline community transition, and their right to be free from retaliation. The facility also failed to submit a monthly list of voluntary and involuntary discharge residents to the [NAME] and [NAME] program. This failure has the potential to affect all 42-residents residing in the facility. Findings Include: On 6/26/24 at 11:00am, the first-floor bulletin board observation was conducted with surveyor, V1 (Administrator) and V3(Admissions) for the [NAME] and [NAME] Retaliation poster. All parties verified that there was no visible poster of the mentioned advocacy group in the facility. On 6/26/24 at 11:30am, the dining and activity rooms were observed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the Wound Care Plan by not implementing effective interventions to prevent further alteration in skin integrity. This failure affected 1 resident (R44) of 3 residents reviewed for wounds in a total sample of 15. Findings Include: On 6-25-24 at 8:03 AM, R44 was noted laying on a low air loss mattress with the mattress setting at static. On 6-27-24 at 11:00 AM, R44 was noted laying on a low air loss mattress with mattress set at static and verified with V11 (Assistant Director of Nursing/ADON). On 6-27-24 at 11:00 AM, V11 (ADON) said the low air loss mattress helps with wound healing by alternating pressure relief. V11 said the alternating pressure setting is based on the resident's weight. V11 said static setting is when all chambers are full and there is no alternating pressure relief for the resident. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the Medication Policy by not labeling medication bottles with the opened date. This failure affected 3 residents (R24, R34, and R18) of 15 residents reviewed for medications. Findings Include: On 6-26-24 at 1:10 PM surveyor found R24's Ketoconazole Shampoo 2%, R34's levocarnitine Oral Solution, and R18's liquid Ondansetron were opened without any opened date on the label. On 6-26-24 at 1:13 PM, V10 (Licensed Practical Nurse/LPN) said the opened date is important because staff can tell when it expires and how long the medication can last. V10 said the opened date lets staff know when to discard. On 6-26-24 at 1:45 PM, V9 (LPN) said when accessing medications she would label with the opened date and note the expiration date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pressure ulcer treatments and/or prevention interventions were implemented and/or completed, as ordered, for 3 of 3 residents (R3, R6, and R8) reviewed for wounds in the sample of 13.

Inspectors wroteBased on interview and record review the facility failed to have a Registered Nurse working 8 hours a day, 7 days a week. This failure has the potential to affect all 37 the residents currently residing in the facility.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain and monitor the temperature of the medication refrigerator in the medication room. This deficiency has the potential to affect all 38 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to date open food items in the kitchen's freezer and failed to air dry food preparation equipment. This deficiency has the potential to affects the entire 38 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to state in their arbitration rider contract agreement that neither the resident nor his or her representative is required to sign the arbitration agreement as a condition of admission to, or as a requirement to receive care at the facility per federal regulation. This failure effects all 38 residents in the facility that were presented with the arbitration agreement.

Inspectors wroteBased on observation, interview and record review, the facility failed to test for legionella and other opportunistic waterborne pathogens, failed to perform hand hygiene before exiting a room on isolation with contact precautions, and failed to clean the blood glucose machine between residents. This failure has the potential to affect all 38 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement an antibiotic stewardship program. This deficient practice has the potential to affect two of two resident R15 and R140 reviewed for antibiotics in a sample of 12 residents.

Inspectors wroteBased on interview and record review, the facility failed to provide influenza/Pneumococcal immunization as required or appropriate for five of five residents R11, R12, R15, R31 and R140 reviewed for Influenza/Pneumococcal Immunization. This deficient practice has the potential to affect all 38 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a hospice plan of care to a resident for one of three residents (R23) reviewed for hospice care in a sample 12.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services to a resident with limited range of motion for one of three residents (R7) reviewed for contractures in a sample of 12.

Inspectors wroteBased on observation, interview and record review, the facility failed to have a written order for an indwelling catheter for one of two residents (R 89) reviewed for indwelling catheters in a sample of 12 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate care to a resident on a feeding tube for one of two residents (R23) reviewed for tube feeding in a sample of 12.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident was free of any significant medication errors for one of six residents (R15) observed for medication administration in a sample of 14.