Inspection visit
Inspection
45 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 45 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based 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.
Residents Affected - Few
Findings include:
On 05/23/2023 at 10:05AM during limited record review, R23's hospice file was noted without coordinated
plan of care. On 05/24/2023 at 12:16PM during review with V2 (Director of Nursing), R23's hospice file was
again noted without the coordinated plan of care and facility's care plan did not indicate R23 is on hospice.
On 05/24/2023 at 12:16PM, V2 stated that R23's hospice file should have the coordinated plan of care in it
and the facility's care plan should address that R23 is on hospice.
R23's Election of Hospice Medicare Benefit and Patient Authorization dated 5/8/2023 indicated effective
date/benefit periods begin on 5/8/2023 and was signed by POA (Power of Attorney) Activated on 5/8/2023.
Facility Agreement Between Hospice signed on 4/22/2015 indicated the following:
Section II
Services to be Furnished by the Hospice
B. Plan of Care
In accordance with applicable Federal and state laws and regulations, Hospice shall coordinate with
Nursing Facility to develop a Plan of Care for the management and palliation of the resident's terminal
illness. The Plan of Care is a written document, which will include a detailed description of the scope and
frequency of hospice services and supplies needed to meet the resident's needs. The Plan of Care will
identify the care and services that are needed and specifically identify which provider is responsible for
performing the respective functions that have been agreed upon and included in the hospice plan of care.
The plan of care will specify which services and supplies are related to the patient's terminal illness and
therefore will be furnished by the Hospice. The Hospice shall furnish a copy of the Plan of Care for such
resident to the Nursing Facility at the time of the resident's admission into the Hospice program.
G. Documentation
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 17
Event ID:
146013
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkeley Nursing & Rehab Center
6909 West North Avenue
Oak Park, IL 60302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Hospice will provide documentation in the Nursing Facility chart, including as appropriate:
Level of Harm - Minimal harm
or potential for actual harm
1) The most recent hospice plan of care and updates if specific to each patient.
Section III
Residents Affected - Few
Services to be furnished by the Nursing Facility
B. Services
With respect to the management of the patient's terminal illness, the Nursing Facility shall:
5. In accordance with applicable Federal and state laws and regulations, nursing facility shall follow Hospice
Plan of Care for each Hospice Patient and provide Hospice Services only with the express authorization of
Hospice.
6. Nursing Facility will coordinate with Hospice in developing a Plan of Care for each Hospice Patient and
will assist with periodic review and modification of the Plan of Care for each Hospice Patient.
Facility Policy:
Title: Procedure for Care Plans
III. Updating of Care Plans
1. It is the responsibility of the Care Plan Coordinator and the MDS (Minimum Data Set) interdisciplinary
team members to update Care Plans for worsening of problems or establish new Care Plans for newly
identified concerns with review of the 24-hour nursing report and any potential re-admissions following an
acute hospital stay and/or ER visit. Care Plan revision will be made as needed following the wound care
meeting, fall risk meeting and NAR meeting.
2. If the Care Plan/MDS team members have identified changes, then the team will begin a new
observation period to determine if a significant change has occurred or if the sudden change is just
temporary condition change that will be resolved after interventions are added.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146013
If continuation sheet
Page 2 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkeley Nursing & Rehab Center
6909 West North Avenue
Oak Park, IL 60302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
Based 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.
Residents Affected - Few
Findings include:
On 05/23/2023 at 10:00AM, R7 was observed sitting in his wheelchair in the dining room with a left hand
contracture and no resting hand splint on.
On 05/24/2023 at 9:25AM, R7 was observed sitting on his wheelchair in the dining room with left hand
contracture and no resting hand splint on. He was also observed with no knee splints on both knees.
On 05/24/2023 at 9:30AM during observation with V2 (Director of Nursing - DON), she said that R7 should
have his left-hand splint and both knee splints on. On 05/26/2023 at 12:00PM, she said that she did not see
any restorative assessment for R7.
On 05/26/2023 at 10:02AM, V20 (Restorative Aide) stated R7 had the splint on Tuesday (5/23/2023) but he
removed it because he had a therapy session, but she said that on Wednesday (5/24/2023), she was
working as a Certified Nursing Assistant (CNA) on the floor and when she works on the floor, she focuses
on her duties as CNA and does not know it the splints are applied on the residents. She also mentioned
that she saw R7 without the splint on that day and she did not know what happened. She also said that she
works as a CNA between three to four times a week in a five-day working schedule. She also added that
she heard about R7 having both knee splints about a year ago but never saw both. She said she only saw
one for the left knee, but it was missing since a year ago and was never replaced. She also mentioned that
there is no restorative nurse currently, but a restorative consultant comes in to do the assessments. She
said that the consultant was asking her for restorative assessment forms, but she was not sure where to
locate them and if she found them. She said she never saw resident assessment forms before and only was
made aware of the programs verbally since she is in constant communication with therapy and restorative
nurse or the DON in the absence of the restorative nurse, so that's what she does to the residents. She
also said that they used to have restorative program tracking, but it is missing and not sure where it is.
On 05/26/2023 at 11:35AM during review with V13(Physical Therapy Assistant) of the physician's order for
R7, V13 said that R7 had recently acquired the knee splints for both knees in April and was only being
applied during therapy. She said that R7 was recently evaluated for therapy due to fall, concern for decline
on left upper extremity and overall deconditioning. She also mentioned that it is possible that R7 declined
because the hand splints and the knee splints were not being applied to R7 consistently. She also added
that R7 cannot apply the hand splint and the knee splints by himself and would need assistance in putting it
on.
R7's order summary report dated 5/25/2023 indicated admission date of 11/06/2014, diagnoses including
hemiplegia unspecified affect left nondominant side and other sequelae of other cerebrovascular disease,
and order for BLE (both lower extremity) knee splints for contractures with order date of 06/06/2022 and left
resting hand splint in the morning and remove at bedtime with order date of 01/14/2017. Care plan revised
08/07/2022 indicated R7 has resting hand splint due to contracture to left
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146013
If continuation sheet
Page 3 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkeley Nursing & Rehab Center
6909 West North Avenue
Oak Park, IL 60302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
hand/wrist/finger, left elbow secondary to left hemiparesis from a CVA (cerebrovascular accident). R7's
physical therapy evaluation and treatment dated 4/11/2023 indicated long-term goal of safely wearing knee
extension splint on both knees. R7's occupational therapy evaluation and treatment dated 4/20/2023
indicated long-term goal of safely wearing an elbow extension splint and a hand roll on left elbow and hand.
Residents Affected - Few
Facility Policy:
Title: Restorative Nursing Program
Date: 01/05/09
Procedure:
4. The licensed nurse must complete Restorative/rehabilitation Quarterly Evaluation for each specific
restorative program quarterly with the MDS.
7. The restorative staff will assemble unit Restorative Program Record Binders to include the resident
specific program records. Each resident will have one restorative program records sheet for each
restorative program that they are participating in. The unit staff and/or restorative aides will record the
minutes provided and their initials with administration of the restorative programming.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146013
If continuation sheet
Page 4 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkeley Nursing & Rehab Center
6909 West North Avenue
Oak Park, IL 60302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
Based 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.
Findings include:
On 5/23 - 5/25/23 at 8:30 am, R 89 was observed in his room, in bed with an indwelling catheter in place.
On 5/25/23 at 10:30 am, V 16 (LPN) stated that R19 should have a written order for a catheter, and
whoever admitted him should have put in an order.
On 5/23/23 at 10:35 am, V14 (Nurse Practitioner) stated that there should be a written order before a
catheter can be inserted.
On 5/26/23 at 12:30 PM, V2 (DON) stated that nurses are to get an order from the physician before
inserting an indwelling catheter as well as for residents coming into the facility with an indwelling catheter.
89's care plan initiated 4/14/23 reads that R 89 has an indwelling catheter in place. Position catheter bag
and tubing below the level of the bladder and away from the room door.
Order summary report dated 5/3/23 reads; Monitor and record amount/character of urine every shift for
urine catheter.
Facility unable to provide policy on inserting indwelling catheter.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146013
If continuation sheet
Page 5 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkeley Nursing & Rehab Center
6909 West North Avenue
Oak Park, IL 60302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
Based 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.
Residents Affected - Few
Findings include:
On 05/23/2023 at 7:03 AM during observation, R23 was observed with an unlabeled enteral feeding pump
bag filled with feeding formula attached to his feeding tube.
On 05/24/2023 at 9:55 AM, R23 was observed with enteral feeding pump bag filled with feeding formula
attached to his feeding tube with label that reads date/time 05/23/23 6AM. At 1:00PM, the label reads the
same date/time of 5/23/23 6AM.
On 05/23/2023 at 7:06AM during observation with V5 (Licensed Practical Nurse), he said that R23's tube
feeding should be labeled.
On 05/24/2023 at 9:58AM during observation with V2 (Director of Nursing), she said that R23's tube
feeding should have been changed. She also mentioned that the same bag can be refilled and used for 24
hours since it is an open system tube feeding.
R23's Order Summary Report dated 5/25/2023 indicated admission date of 04/08/2023, diagnosis including
dysphasia following cerebral infarction and nontraumatic intracerebral hemorrhage in hemisphere, and
order for tube feeding with order date of 5/23/2023.
Facility Policy:
Title: Enteral Tube Care and Feeding
Revised 11/01/11
Purpose: To describe care and use of enteral tube and feeding with continuous, intermittent, closed and
open system.
Procedure:
13. Keep administration set intact for feeding for maximum if 48 hours; if open system, change feeding
container and administration set every 24 hours.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146013
If continuation sheet
Page 6 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkeley Nursing & Rehab Center
6909 West North Avenue
Oak Park, IL 60302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Actual harm
Based 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.
Residents Affected - Few
Findings include:
On 05/23/23 at 8:30 AM R139 was observed lying in bed, soft spoken, and V16 (LPN) at bedside. V16
asked how R139 was doing and R139 states her neck hurts. V16 states oh your neck is still hurting. V16
then leaves the room without asking R139 her pain level. R139's chin is to her chest and the resident looks
uncomfortable. Surveyor asked R139's pain level from 1-10. R139 states her pain level is 9/10. R139 states
the nurse gave her extra strength acetaminophen medication. R139 states she is waiting for it to work, and
states she has been in pain since she had a stent/surgery.
On 05/23/23 10:30 AM R139 states pain is still 7/10. R139 states she only had the extra strength
acetaminophen earlier and nothing else.
On 05/24/23 09:54 AM R139 states her pain is 10/10. R139 states she doesn't remember seeing a nurse
today.
On 05/24/23 at 9:56 AM V2 (DON) standing in the hall at the medication cart states she is working the floor
today. V2 states she saw the resident at about 8 am. R139 states R139 has a narcotic pain medication for
high levels of pain. V2 states residents can have narcotics if they request it and for pain level of 5 or above.
On 05/24/23 09:58 AM R139 is observed lying in bed with her chin to her chest and looking uncomfortable.
R139 states she is in pain and the staff doesn't believe her when she tells them. R139 states because I'm
not screaming and hollering they don't believe me. I'm a person and this is my body. I wouldn't lie about
that. R139's arms observed visibly shaking. R139 states she is not sure if shaking is because of pain or
something else. R139 states she can get confused because of the pain. R139 states they tell her You are
okay. R139 states, My head, neck and shoulders hurt. My neck on the right side is worse than the left side. I
scream when they turn me over to the left side to change me. At 10:03 AM V2 comes into the room and
says to R139 do you want the strong stuff, for pain. R139 states yes, to the offer of a stronger pain
medication. V2 starts to leave the room. Surveyor asks do you ask what the pain level is? V1 says, yes, and
comes back to ask pain level. R139 states pain is 10. R139 says, I cried in my sleep because pain was so
bad. V2 states, I don't want you to cry, and she would get R139 some pain medication. At 10:05 AM V2
leaves the room, then Resident starts crying and says Thank you. While crying R139 states I want to die.
R139 states, I want to die because it hurts so bad. I love to be alive, but this pain is so stressful. R139
states she was in pain all night.
On 5/24/23 at 10:08 AM V2 at medication cart and surveyor tells V2 that R139 was crying and said she
wants to die because of the pain. V2 states she will let the doctor/social services know.
R139's progress note by V2 dated 5/24/2023 at 10:50 AM documents the following: Resident complaining
of generalized pain to body. Stated it was 10 out of 10. Resident only had Tylenol ordered. Given as
ordered. Called V22 (Dr.) ordered to refer to palliative care for evaluation and management of pain.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146013
If continuation sheet
Page 7 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkeley Nursing & Rehab Center
6909 West North Avenue
Oak Park, IL 60302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0697
On 5/24/2023 at 11:08 Am R139 states her pain is 10/10.
Level of Harm - Actual harm
On 5/24/2023 at 11:10 AM V10 CNA states R139 gets real scared a lot when you are going to turn her. I tell
her to take a deep breath.
Residents Affected - Few
On 5/24/23 at 11:15 AM V21 (Therapy) states she is working with R139. V21 states V21 had complained of
head and neck pain on Monday.
On 05/24/23 11:30 AM V6 (CNA) states on Saturday R139 said her right leg and right side was hurting and
then her stomach was hurting. She said whole right side of her head and neck was hurting on Saturday. V6
states she told V9 (nurse) on Saturday about R139's pain.
On 05/24/23 02:18 PM R139 states her pain is a little better and is 7/10. R139 states she would like pain
relief.
On 5/24/2023 at 2:57 PM with V6 (CNA), V10 (CNA) and V13 (PTA) to observe ADL care. Surveyor asked
R139 her pain level. R139 states it is a 5/10. R139 is anxious while they cleaned the front of her. V13 states
resident is anticipating pain and gets apprehensive. R139 gets very anxious starts saying oh and breathing
fast and rolling her eyes, shaking, and quivering more intensely. V10 states she has seen her do this before.
R139 calms down and says be careful before they were going to turn her. When they turned R139 on her
left side, R139 screamed Ohhhh! and kept saying oh. No one asked R139 if she was in pain. Surveyor then
asked staff has she ever screamed like that before when you turned her. V6 and V10 both said yes, all the
time. V10 states she always does that. V10 said she considered that a moan. V6 and V13 were in
agreement. Surveyor asks R139 if she was in pain and R139 said yes, it hurts. My neck is hurting.
On 5/25/2023 at 9:16 AM surveyor asks R139 how she is doing. R139 states, I'm still hurting. Pain is still
the same. When asked what number on scale of 1-10, R139 states 10.
On 5/25/2023 at 9:18 AM surveyor informed V16 (LPN) that R139's pain was 10/10. V16 states she will go
see her. V16 states she gave R139 pain medicine on Tuesday 5/23/2023 and when she rechecked R139's
pain level she was still in pain. R139 states she then asked V14 (APN) to see her because R139 was still in
pain after the Tylenol.
On 5/25/2023 at 9:33 AM V14 (APN) states she saw R139 on Tuesday and R139 said she is having neck
pain and pain on the side of the Peripherally Inserted Central Catheter (PICC) line. V14 states she doesn't
remember her pain level and she didn't chart it because she was not billing R139. V14 states she ordered
PICC line be taken out. V14 (APN) states V16 (nurse) told her to see R139 today because of pain.
On 5/25/2023 at 10:19 AM V14 (APN) states she saw resident and she has pain of 10/10 consisting of a
headache, neck pain, and right chest pain that radiates to the left side. V14 states she is going to send
R139 out to the hospital because R139 said her head pain is the worst she has ever had.
On 5/25/2023 at 2:33 PM V22 (Primary Care Provider) states the nurse called him regarding R139's pain.
V22 states the nurse stated that R139's pain was uncontrolled and nothing was working and they (facility)
had tried everything. V22 states, had he known that R139 only had acetaminophen on board for pain, he
would have tried to add something else like Naproxen, or Neurontin. V22 states kidney problems and
R139's history is no reason not to treat R139's pain. V22 states when routine things are
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146013
If continuation sheet
Page 8 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkeley Nursing & Rehab Center
6909 West North Avenue
Oak Park, IL 60302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0697
not helping pain then he would recommend palliative care for pain control. V22 states he ordered palliative
care for the resident because the nurse said they had tried everything.
Level of Harm - Actual harm
Residents Affected - Few
On 5/26/2023 at 12:22 PM V2 (DON) states the nurse should ask about pain every shift minimally or if you
have someone always complaining, then they should ask more often. V2 states the facility should ask pain
level, what kind of pain, look at vital signs, facial expressions, if guarded, moaning, screaming, or
grimacing, fearful, don't want you to touch them; these are all signs of pain. V2 states they use different
interventions to relieve pain. In general, we should write a note about what a resident said and what
intervention provided and how the resident received the pain management intervention. If it was effective or
ineffective. V2 states, if you don't document on the Medication Administration Record (MAR) the pain level,
the reminder to reassess pain doesn't pop up. V2 states for uncontrolled pain they try to see what's working
and try to alleviate pain and should call doctor and let the doctor know.
R139's Therapy note by V21 (Occupational Therapist Aide) dated 5/19/2023 documents pain present on
assessment. Pain limits patient's functional activity.
R139's Therapy note by V23 (Occupational Therapist) dated 5/23/2023 documents R139 reports pain on
neck.
Review of R139's pain assessments, is empty of any documented pain level.
Review of R139's care plan is absent of a care plan for pain.
Review of R139's medication administration record is absent of any documentation that any pain
medication was given.
The facility's Pain management policy documents the following: Policy: Our mission is to facilitate resident
independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to
accomplish that mission through an effective pain management program, providing our residents to means
to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement.
We will achieve these goals through:
Promptly and accurately assessing and diagnosing pain
Monitoring treatment efficacy and side effects.
Preventing and minimizing anticipated pain when possible.
B. The licensed nurse will repeat the comprehensive pain assessment under any of the following
circumstances:
* Resident is on routine pain medication and pain is not controlled, persistent, or worsening.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146013
If continuation sheet
Page 9 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkeley Nursing & Rehab Center
6909 West North Avenue
Oak Park, IL 60302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
Based 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.
Residents Affected - Few
Findings include:
On 05/23/2023 at 11:45AM during medication administration observation, V16 (Licensed Practical Nurse)
was observed pulling out the regular human insulin vial from the cart and withdrawing 2 units from it without
checking the expiration date. V16 handed the vial to the surveyor for review and was noted with open date
of 4/1/2023.
On 05/23/2023 at 11:45AM during observation with V16, she said that the regular human insulin vial was
opened 4/1/2023 and should have been discarded after 28 days of opening. She also said that she used
the same vial the day prior for medication administration observation since there is no other vial of regular
insulin in the cart.
On 05/23/2023 at 12:22PM during observation with V2, V2 (Director of Nursing) stated that the regular
human insulin should have been discarded after 30 days.
On 05/26/2023 at 12:45PM, V24 (Pharmacist) said that regular human insulin should be discarded 31 days
after opening and kept in room temperature.
R15's order summary report date 05/26/2023 indicated admission date of 01/10/2023, diagnoses include
type 2 diabetes mellitus without complications, and order for insulin regular human solution sliding scale
with order date of 01/10/2023. R15's medication administration record for May 2023 indicated insulin
regular human solution had been given at least daily from May 1-13 and May 16-23, 2023.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146013
If continuation sheet
Page 10 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkeley Nursing & Rehab Center
6909 West North Avenue
Oak Park, IL 60302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
On [DATE] at 12:15PM during observation with V16 (Licensed Practical Nurse), the medication refrigerator
was observed with a temperature of 32 degrees Fahrenheit (F) and the refrigerator temperature log for
[DATE] with missing entries from [DATE] to [DATE]. The refrigerator was observed with unopened insulin
pens, vials, house stock suppositories, house stock insulins, comfort kits, and R15's intravenous antibiotics.
On [DATE] at 12:10PM during observation with V16, the medication refrigerator was observed with a
temperature of 54 degrees F and the refrigerator temperature log for [DATE] with missing entries from
[DATE] to [DATE] and [DATE].
On [DATE] at 12:11PM, V16 said that the medication refrigerator temperatures should be checked daily and
adjusted to maintain the normal temperature range. She also said that if it is out of range and cannot be
controlled, maintenance has to be informed to check it.
Facility Policy:
Undated Policy Title: Medication Storage and Handling
4. Medications with Storage Requirements for temperature, light, or humidity controls must be stored to
meet specifications for the medication.
5. Medications will be monitored by the Unit Nurse, Charge Nurse, and Consultant Pharmacist to assure
that they are not Expired, Contaminated, or Unusable.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146013
If continuation sheet
Page 11 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkeley Nursing & Rehab Center
6909 West North Avenue
Oak Park, IL 60302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based 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.
Findings include:
On 5/23/23 at 6:45am, refrigerator #5 was observed with 4 pans of apple pie prepared 5/9/23 with no
expiration date and 2 bags of whipped cream prepared on 5/8/23 with no expiration date.
On 5/24/23 at 11:30am, V4(Cook) pureed chicken nuggets, ran the blender through the dishwasher and
was about to use the same blender to puree fried rice, but the surveyor intervened and stopped V4 from
using the same blender.
On 5/23/23 at 7:00am, V4(cook) stated that all food should have an expiration date. V4 stated the bags of
whipped cream should have a date. I will toss it, I don't' know who did it. V4 and V3 (Dietary Manager) both
stated that the blender should be air dried before use.
Facility policy dated 4/2017 reads: Food Safety and Sanitation.
Policy. The facility will follow safe handling and storage of PHF (Potentially Hazardous Foods (and TCS
(Temperature Control for Safety)
Procedure. PHF/TCS food will be stored, dated, and labeled in the refrigerator held at 41 degrees for a
maximum of seven days
All items not in their original container will be labeled.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146013
If continuation sheet
Page 12 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkeley Nursing & Rehab Center
6909 West North Avenue
Oak Park, IL 60302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0847
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Level of Harm - Minimal harm
or potential for actual harm
Based 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.
Residents Affected - Many
Findings include:
During the Review of the facility's Arbitration Rider Contract, no language was found that states 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.
On 5/25/23 at 1:35 PM V15 (admission Director) states she read the contract and also did not find any
language that states 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.
On 5/26/23 at 10:38 AM V15 states resident contracts includes the arbitration agreement and she goes
over the entire contract.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146013
If continuation sheet
Page 13 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkeley Nursing & Rehab Center
6909 West North Avenue
Oak Park, IL 60302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based 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.
Residents Affected - Many
Findings include:
On 5/25/23 at 12:00pm, and interview was conducted with V2 (Director of Nursing/Infection Preventionist).
V2 stated that the facility does test for legionella. V2 stated I am new here and trying to put things in place.
On 5/25/23 at 12:25pm, both V1(Administrator) and V7 (Maintenance/HK/laundry Director) stated that the
facility does not perform any testing for legionella and other opportunistic waterborne pathogens.
Facility unable to provide a policy on legionella testing.
On 05/23/2023 at 11:30AM and 11:45AM during blood glucose monitoring observation, V16 (Licensed
Practical Nurse) was observed placing the blood glucose machine on the bedside tables of R89 and R15
noted with clear, dried liquid stains. She performed blood glucose checks on R89 and R15, then she went
back to the medication cart and placed the blood glucose monitoring machine inside the medication carts
without cleaning or disinfecting it.
On 05/23/2023 at 12:03PM during blood glucose monitoring observation, R140's room was observed with
sign that reads Stop Contact Precaution. V16 was observed placing the blood glucose machine on the
bedside table of R140 noted with clear, dried liquid stains. She performed a blood glucose check on R140,
removed her gown and gloves, and left the room without performing hand washing.
On 05/23/2023 at 12:11PM, V16 said that she should have just held the blood glucose monitoring machine
while performing the blood glucose check and cleaned it after each resident use. She also said that she
should have washed her hands with soap and water before exiting the room.
R140's Order Summary Report dated 5/25/23 indicated admission date of 5/10/2023, diagnosis including
type 2 diabetes mellitus and order for contact isolation for C-diff (Clostridium difficile) with order date of
05/18/2023. R140's laboratory report dated 05/18/2023 indicated positive for Clostridioides difficile toxin.
Facility Policies:
Title: Blood glucose monitoring
Updated 10/18/2010
8. Clean the accucheck (blood glucose monitoring) machine.
Title: Hand Hygiene
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146013
If continuation sheet
Page 14 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkeley Nursing & Rehab Center
6909 West North Avenue
Oak Park, IL 60302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Revised 04/15/13
Level of Harm - Minimal harm
or potential for actual harm
Purpose: Hand Hygiene is the single most efficient means of preventing the spread of infection.
Indications for Hand Washing and Hand Antisepsis
Residents Affected - Many
Hand Washing
Wash hands with either non-antimicrobial soap and water or an antimicrobial soap and water if exposure to
a spore forming organism is suspected or proven.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146013
If continuation sheet
Page 15 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkeley Nursing & Rehab Center
6909 West North Avenue
Oak Park, IL 60302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0881
Implement a program that monitors antibiotic use.
Level of Harm - Minimal harm
or potential for actual harm
Based 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.
Residents Affected - Many
Finding include.
During record review on 5/25/23 at 12:00pm, it was noted that, R15 was receiving intravenous antibiotic for
osteomyelitis that started on 5/23/23 once a day for two weeks. R140 was receiving oral antibiotic for
Clostridium difficile that started on 5/18/23 twice a day for ten days. The facility did not have antibiotic use
protocol on prescribing antibiotics, a review on clinical sings and symptoms and a process of periodic
review of antibiotics by health practitioners.
On 5/25/23 at 12:00pm, during infection control meeting, V2(DON/IP) stated that the facility does not have
an antibiotic stewardship program. V2 stated I only have a list of residents on antibiotics.
Facility unable to provide a policy on antibiotic stewardship program.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146013
If continuation sheet
Page 16 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkeley Nursing & Rehab Center
6909 West North Avenue
Oak Park, IL 60302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
Based 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.
Residents Affected - Many
Findings include:
During record review on 5/25/23 at 12:00pm, it was noted that R11 last received Prevnar 13 on 9/14/16,
R12 last received Prevnar 13 on 9/14/16, R15, R31 and R140 all have no immunization record for
Influenza/Pneumococcal. The above residents have no contraindication for Influenza/Pneumococcal
immunization.
During an interview on 5/25/23 at 12:00pm with V2(DON/IP), V2 stated that residents should receive
immunization every year. V2 stated I have not had time to check who has received one.
Facility policy dated 3/2016 reads: Policy for administration of Pneumococcal Vaccine.
Purpose: To provide a policy for the administration of the pneumococcal vaccine.
Process:
1. All residents and/or their responsible parties will be asked on admission if they have received the
pneumococcal vaccine.
2. It they have not received the vaccine; an order will be obtained to give the vaccine .
Facility policy dated 10/10/06 reads, Pneumococcal Vaccination of Residents.
#2. Administration Procedure:
A. Each resident's pneumococcal immunization status will be determine upon admission or soon
afterwards, and will be documented in the resident's medical record
B. All residents with undocumented or unknown pneumococcal vaccination status will be offered the
vaccination during the current/next flu season.
F. Vaccine will be administered according to standing order .to all residents who meet vaccination criteria.
Facility Influenza (Flu) Vaccination of Residents, staff and Volunteers Guideline and procedure reads.
Guideline:
1. All residents, staff and volunteers of our facility should receive the influenza vaccine annually, unless
there is a documented contraindication.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146013
If continuation sheet
Page 17 of 17
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Back to topCitations
45 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F847 - Entering Into Binding Arbitration Agreements
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0001GeneralS&S Fpotential for harm
Establish an Emergency Preparedness Program (EP).
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0006GeneralS&S Fpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0007GeneralS&S Fpotential for harm
Address patient/client population and determine types of services needed.
- 0013GeneralS&S Fpotential for harm
Develop Emergency Preparedness policies and procedures.
- 0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
- 0018GeneralS&S Fpotential for harm
Establish procedures for tracking staff and patients during an emergency.
- 0020GeneralS&S Fpotential for harm
Establish policies and procedures including evacuation.
- 0022GeneralS&S Fpotential for harm
Establish policies and procedures for sheltering.
- 0023GeneralS&S Fpotential for harm
Establish policies and procedures for medical documentation.
- 0024GeneralS&S Fpotential for harm
Establish policies and procedures for volunteers.
- 0025GeneralS&S Fpotential for harm
Create arrangements with other facilities to receive patients.
- 0029GeneralS&S Fpotential for harm
Develop a communication plan.
- 0030GeneralS&S Fpotential for harm
List the names and contact information of those in the facility.
- 0031GeneralS&S Fpotential for harm
Provide emergency officials' contact information.
- 0032GeneralS&S Fpotential for harm
Provide primary/alternate means for communication.
- 0033GeneralS&S Fpotential for harm
Establish methods for sharing information.
- 0034GeneralS&S Fpotential for harm
Provide a means of sharing information on occupancy/needs.
- 0035GeneralS&S Fpotential for harm
Provide family notifications of emergency plan.
- 0036GeneralS&S Fpotential for harm
Establish emergency prep training and testing.
- 0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0041GeneralS&S Fpotential for harm
Implement emergency and standby power systems.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351GeneralS&S Fpotential for harm
Install an approved automatic sprinkler system.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0511GeneralS&S Fpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0541GeneralS&S Fpotential for harm
Install properly constructed and protected linen or trash chutes.
F915 - Buildings must have an outside window or outside door in every
Have proper power supply for life support equipment.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
- 0929GeneralS&S Epotential for harm
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
FAQ · About this visit
Common questions about this visit
What happened during the May 26, 2023 survey of BERKELEY NURSING & REHAB CENTER?
This was a inspection survey of BERKELEY NURSING & REHAB CENTER on May 26, 2023. The surveyor cited 45 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BERKELEY NURSING & REHAB CENTER on May 26, 2023?
Yes, 45 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.