Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Berea Health & Rehab Center during CMS and state inspections, most recent first.
Improper Storage of Refrigerated Food: During a kitchen observation, a two-gallon zip lock bag of fish in the walk-in refrigerator was found unsealed. The cook sealed the bag during the observation and stated that refrigerated food should be kept in sealed containers. The facility policy requires all food and leftovers to be stored in covered, approved, food grade containers.
A RN used the same BP cuff and monitor on two residents without disinfecting the equipment between uses, and later used it again on another resident without cleaning it before or after use. In a separate observation, a housekeeper/laundry aide moved a bin of soiled laundry through the clean side of the laundry room instead of using the soiled-laundry entrance, contrary to the facility's linen handling process.
A resident with severe cognitive impairment was observed having BP taken at a dining room table while seated with two other residents during breakfast. The RN rolled a vital sign monitor to the table and checked the BP in the open dining area. Staff interviews stated vital signs were normally taken in residents’ rooms for privacy and resident rights, and the facility policy stated it complies with resident rights.
A resident with CHF had an ordered fluid restriction that was provided in the MARs and observed in practice, but the care plan did not include the restriction even though staff said it should be there for CNA access. Another resident’s care plan called for bilateral floor mats, but only one mat was in place while the other was rolled up in the room. A third resident with an indwelling catheter had a care plan directing that no part of the drainage system touch the floor, yet the catheter bag was observed on or touching the floor during multiple observations.
An RN crushed and administered a delayed-release pantoprazole tablet to a resident even though the order did not include crushing instructions. An LPN said crushed meds are checked on the eMAR, and the pharmacist stated pantoprazole should not be crushed because it can change the medication; the pharmacy reference also listed it as a medication that should not be crushed.
A resident with a history of falls and multiple fall risk factors had a care plan calling for bilateral floor mats, but staff observed only one mat in place while the resident was in bed and the other mat rolled up against the wall. An LPN stated that bilateral mats should be on the floor on each side of the bed when the resident is in bed.
A resident with an indwelling urinary catheter for urinary retention, neurogenic bladder, and obstructive/reflux uropathy was observed with the drainage bag touching the floor while in bed. The bag was seen on the floor more than once, and the resident said it was leaking and staff had been told earlier. The care plan and facility policy both stated the drainage system should not touch the floor.
Failure to Honor Documented Food Allergy: A resident with a documented pineapple allergy was served ham that had been cooked with pineapple and then had the pineapple removed before serving. The resident was cognitively intact, the meal ticket identified the allergy, and the DM confirmed the ham should have been cooked separately but was not.
Failure to administer/document a pneumococcal vaccine was identified for a resident with short- and long-term memory deficits and severe cognitive impairment. The EHR showed VIS education and consent from the resident and RP, but staff could not locate documentation showing the vaccine was actually administered. The ADON stated the date and lot number should be documented in the EHR, but no administration record was found.
Failure to document COVID-19 vaccine administration for a resident with severe cognitive impairment. The EHR showed vaccine education was provided and consent was obtained from the resident and RP, but staff could not locate documentation that the vaccine was actually administered, including the date and lot number. The ADON stated the resident’s spouse recalled the resident had received the vaccine, but the record did not evidence when it was given.
Facility staff did not notify the provider or resident representative when two residents experienced multiple episodes of blood glucose readings above 400 mg/dL, despite physician orders and facility policy requiring such notifications. Nursing staff confirmed awareness of the requirement, but clinical records lacked evidence of any notifications following these critical events.
Facility staff did not follow provider orders to notify the provider when two residents' blood sugar levels exceeded 400, as required by sliding scale insulin protocols. Despite multiple documented instances of elevated blood sugar, there was no evidence in the clinical records that the provider was contacted, and staff interviews confirmed the expectation to notify providers in such cases.
Improper Storage of Refrigerated Food
Penalty
Summary
Food was not stored in a sanitary manner in one of one kitchens. During an observation in the walk-in refrigerator, a two-gallon zip lock bag containing fish dated 3/2/26 was found unsealed. The cook sealed the bag during the observation and stated that the bag should have been completely sealed and that the facility standard is to keep refrigerated food in sealed containers. The facility’s policy for storage of refrigerated foods states that all food and leftovers are to be stored in covered, approved, food grade containers.
Failure to Disinfect Shared Equipment and Separate Soiled Laundry Flow
Penalty
Summary
Facility staff failed to follow infection control practices when a registered nurse used the same blood pressure cuff and vital sign monitor on two residents without disinfecting the equipment between uses. On 3/4/2026 at 8:15 AM, the RN was observed checking the blood pressure of Resident #75 in the dining area and did not disinfect the cuff afterward. At 8:23 AM, the same RN used the same blood pressure cuff and monitor to check the blood pressure of Resident #26 in the resident's room without disinfecting it before or after use. The RN later stated that blood pressure cuffs should be cleaned with disinfectant wipes after each use and said she had forgotten to do so during the observation. The same equipment was then used on Resident #17 without disinfection. At 8:23 AM, the RN was observed using the blood pressure monitor and cuff in Resident #26's room without disinfecting it after that use, and at 8:37 AM the RN used the same monitor and cuff to check Resident #17's blood pressure in the resident's room without disinfecting it prior to or after use. In a separate finding, the facility did not use a separate entrance for soiled laundry into the laundry room. On 03/05/2026 at approximately 10:00 AM, observation showed a housekeeper/laundry aide pushing a bin of soiled laundry through the entrance into the clean side of the laundry room and down the hallway to the washers instead of entering through the soiled laundry door. The Director of Housekeeping and Laundry stated that clean and soiled laundry should not be taken in and out through the same door to prevent cross contamination.
Dignity Not Maintained During Blood Pressure Check in Dining Room
Penalty
Summary
The facility staff failed to promote dignity for one resident when a registered nurse checked the resident’s blood pressure at a dining room table during breakfast on 3/4/2026. The resident’s most recent MDS quarterly assessment, with an ARD of 11/25/2025, showed a BIMS score of 4 out of 15, indicating severe impairment in making daily decisions. At the time of the observation, the resident was seated in the dining area with two other residents, had finished breakfast, and was still at the table while the nurse rolled a vital sign monitor to the table and took the blood pressure there. During interviews on 3/5/2026, an LPN stated that vital signs were normally taken in residents’ rooms and that staff usually waited if a resident was in the dining room, explaining this was done for privacy and resident rights because care in open areas lacked privacy. A CNA stated that if she were taking vital signs, they would be done in the resident’s room and not in public areas. The facility’s Resident Rights and Facility Responsibility policy, revised 10/7/25, stated that it is the facility’s policy to comply with all resident rights.
Care plans were incomplete or not followed for fluid restriction, fall protection, and catheter care
Penalty
Summary
The facility failed to develop a comprehensive care plan for fluid restriction for a resident with diagnoses including CVA, CHF, pneumonitis, and chronic respiratory failure. The resident’s quarterly MDS coded a BIMS score of 15 out of 15, indicating no cognitive impairment. The existing care plan addressed impaired cardiovascular status related to CHF and included monitoring and documenting signs and symptoms of CHF, but it did not include the ordered 1500 mL/24 hour fluid restriction. Physician orders dated 1/13/26 specified the fluid restriction, with dietary and nursing assigned portions of the daily allowance, and the January through March 2026 MARs showed the restriction was provided as ordered. Observations on 3/4/26 and 3/5/26 showed the resident on fluid restriction as ordered, and an LPN stated fluid restriction should be on the care plan because CNAs do not have access to the MAR. The facility also failed to implement care plans for two other residents. One resident’s care plan identified bilateral floor mats due to fall risk related to muscle weakness, reduced mobility, osteoarthritis, psychotropic medication use, incontinence, and impaired safety awareness/dementia, but observations showed only one floor mat on the left side of the bed while the other mat was rolled up against the wall in the room corner. Another resident had an indwelling urinary catheter for urinary retention after a failed voiding trial, and the care plan directed staff not to allow tubing or any part of the drainage system to touch the floor. However, observations showed the catheter bag on the floor, touching the floor surface while the resident was in bed, and again hanging beside the bed with the bed in the lowest position and the bag touching the floor.
Crushed delayed-release pantoprazole was administered without an order
Penalty
Summary
Facility staff failed to follow professional standards of practice during medication administration for Resident #34. On 3/4/2026 at 8:29 AM, an RN was observed preparing medication for the resident and crushed one 40 mg pantoprazole delayed-release tablet before administering it. The physician order for the resident listed pantoprazole delayed-release 40 mg, one tablet by mouth once daily, with no order documented to crush the medication. During interviews, an LPN stated that crushed medications are reviewed on the eMAR and checked for orders to crush, and that medications are verified before crushing. The pharmacist stated that delayed-release pantoprazole should not be crushed because it can change the medication, and the pharmacy reference Common Oral Dosage Forms That Should Not be Crushed listed pantoprazole as a medication that should not be crushed. The DON, IP/ADON, administrator, and regional director of operations were notified of the finding.
Failure to Maintain Bilateral Floor Mats for a Resident at Risk for Falls
Penalty
Summary
The facility failed to implement fall precautions for one resident who had a history of an actual fall and was identified in the comprehensive care plan as being at risk for falls related to muscle weakness, reduced mobility, osteoarthritis, psychotropic medication use, incontinence, and impaired safety awareness/dementia. The care plan dated 11/19/25 documented bilateral floor mats, but on 3/3/26 at 2:02 p.m. and again on 3/4/26 at 8:38 a.m., the resident was observed lying in bed with a floor mat on the left side only; no mat was present on the right side, and the missing mat was observed rolled up against the wall in the corner of the room. During interview on 3/5/26 at 12:30 p.m., an LPN stated that when a care plan documents bilateral floor mats, a mat should be on the floor on each side of the bed while the resident is in bed.
Catheter drainage bag left touching the floor
Penalty
Summary
The facility failed to maintain an indwelling urinary catheter drainage bag in a sanitary manner for one resident. The resident had diagnoses including urinary retention, neuromuscular dysfunction of the bladder, and obstructive and reflux uropathy. The most recent MDS showed the resident had an indwelling catheter for urinary retention and related bladder conditions, and the care plan directed staff not to allow tubing or any part of the drainage system to touch the floor. On 3/4/26, the resident was observed with the catheter bag touching the floor while lying in bed in the lowest position. The resident stated the bag was leaking and that staff had been informed about 15 minutes earlier. Later that morning, the catheter bag was again observed touching the floor surface on the left side of the bed, and another observation showed the bag hanging on the left side of the bed with the bed still in the lowest position and the bag touching the floor. An RN stated catheter bags should be below bladder level and not on the floor for infection control, and the facility policy also stated the urinary drainage bag must be placed below bladder level but not on the floor.
Failure to Honor Documented Food Allergy
Penalty
Summary
The facility failed to honor a documented pineapple allergy for Resident #15 when the resident was served ham that had been cooked with pineapple on Thanksgiving. The resident’s clinical record showed a pineapple allergy, and the admission MDS with an ARD of 9/10/25 indicated the resident was cognitively intact with a BIMS score of 15 out of 15. During interview, the resident stated the meal ticket documented the pineapple allergy and reported that the facility cooked ham with pineapple, removed the pineapple, and served the ham to the resident. The Dietary Manager confirmed that the ham was cooked with pineapple rings and that the pineapple rings were discarded before the resident was served, stating the ham should have been cooked separately but the cook did not think about it. The facility’s food allergies policy stated that individuals with food allergies will be provided with safe foods and fluids and appropriate substitutions to maintain health.
Failure to Document Pneumococcal Vaccine Administration
Penalty
Summary
Failure to administer the pneumococcal vaccine was identified for one resident during review of the immunization record. The resident’s MDS admission assessment documented short- and long-term memory difficulties and severe cognitive impairment for making daily decisions. The EHR showed that pneumococcal vaccine education was provided, the risks, benefits, and alternatives were reviewed using the VIS, and consent was obtained from both the resident and the responsible party. Despite this documentation, further record review did not evidence that the pneumococcal vaccine was actually administered. During interview, the ADON stated that when the vaccine is given, the date and lot number are documented in the EHR under preventative health, but no documentation could be located showing when the resident received the vaccine. The ADON also stated that the resident’s spouse recalled the vaccinations being given at the facility, and that there had been a batch of expired vaccines at the time the resident was scheduled to receive the pneumococcal vaccine, but the date of administration was not documented.
Failure to Document Administration of COVID-19 Vaccine
Penalty
Summary
The facility failed to administer the COVID-19 vaccine for one of five residents reviewed in the immunization record review, Resident #27. The resident’s most recent MDS assessment documented short- and long-term memory difficulties and severe cognitive impairment for daily decision-making. The EHR showed that COVID-19 vaccine education was provided, the risks, benefits, and alternatives were reviewed using the vaccine information sheet, the resident verbalized understanding, and the responsible party was contacted by phone and gave consent. Despite documentation that education and consent were obtained, further review did not evidence that the COVID-19 vaccine was actually administered to Resident #27. The ADON stated that when the vaccine was administered, the date and lot number should be documented in the EHR under preventative health, but staff were unable to locate documentation showing when the resident received the vaccine. The ADON also stated that the resident’s spouse recalled the resident had received the vaccination at the facility, and that there had been a batch of expired vaccines at the time the resident was scheduled to receive the COVID-19 vaccine, but the date the vaccine was given was not documented.
Failure to Notify Provider and Representative of Critical Blood Sugar Levels
Penalty
Summary
Facility staff failed to notify the provider and resident representative (RR) of significant changes in condition for two residents with diabetes, as required by physician orders and facility policy. For one resident, multiple blood glucose readings exceeding 400 mg/dL were documented in the medication administration records (MARs) over several dates, but there was no evidence in the clinical record that either the provider or RR was notified of these critical results. The provider's order specifically instructed staff to call the medical doctor if blood sugar exceeded 400, yet this was not done. Interviews with nursing staff confirmed that it is standard practice and expectation to notify the provider and RR when blood sugar readings surpass dangerous thresholds, as indicated in the orders. Staff acknowledged that such instructions are routine and must be followed, emphasizing that 'an order is an order.' Despite this, review of the clinical records for both residents showed no documentation of required notifications following high blood sugar readings. The facility's policy on resident change in condition states that the licensed nurse must recognize and intervene in the event of a change, and notify the physician/provider and family/responsible party as soon as the change is identified and the resident is stable. However, in both cases, there was a lack of evidence that these notifications occurred, despite repeated instances of blood sugar levels exceeding the specified threshold.
Failure to Notify Provider of Critically High Blood Sugar Levels per Insulin Orders
Penalty
Summary
Facility staff failed to follow provider orders for the administration of insulin for two residents. For one resident, provider orders specified that if blood sugar exceeded 400, the provider should be notified. Clinical record review showed multiple instances where the resident's blood sugar was above 400, but there was no evidence that the provider was notified as required. Medication administration records documented blood sugar readings above the threshold on several dates, yet the clinical record lacked documentation of provider notification. Interviews with nursing staff confirmed that the standard practice is to notify the provider when blood sugar readings exceed specified parameters in sliding scale insulin orders. Staff acknowledged that an order is to be followed as written, and that both the provider and resident representative should be notified when such parameters are exceeded. However, review of the records indicated that this protocol was not followed for the residents in question. Administrative and nursing leadership were made aware of these concerns during the survey. The facility's policy on provider orders did not include information regarding the nursing staff's responsibility to follow such orders. No additional information or documentation was provided to demonstrate that the provider was notified in the identified cases.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fredericksburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Falls Run Nursing And Rehabilitation | 0 mi | — | 0 | 0 |
| Fredericksburg Health And Rehab | 5.4 mi | — | 2 | 0 |
| Woodmont Center | 5.6 mi | — | 5 | 0 |
| Carriage Hill Health & Rehab Center | 5.9 mi | — | 2 | 0 |
| Heritage Hall King George | 18.2 mi | — | 0 | 0 |
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