Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Berkeley Nursing & Rehab Center during CMS and state inspections, most recent first.
A cognitively intact male resident with dementia and schizoaffective disorder, care planned to be free from mistreatment, was subjected to verbal abuse by a CNA. The CNA, believing the resident was speaking derogatorily about her in Spanish, approached an RN in a loud, angry manner in the resident’s presence, yelled and cursed, raised her arm toward the resident, and threatened to “slap the sh*t out of” him while calling him a vulgar name. Two nurses attempted to calm the CNA, and one RN positioned the resident behind her out of concern the CNA might hit him. Other RNs and the administrator reported they had not heard the resident use racial slurs or curse staff, and the administrator stated staff are expected to walk away, ignore, or respond calmly to negative resident comments, consistent with the facility’s abuse-prevention policy.
A resident with a history of atrial fibrillation and on anticoagulant therapy experienced an unwitnessed fall and was later found with altered mental status. Despite facility policy requiring 911 to be called for unresponsiveness or unstable vital signs, staff delayed calling advanced life support and initially arranged for basic life support transport. The resident's condition was later deemed critical by EMS, requiring intubation and ICU care.
Dietary staff did not change gloves or sanitize hands after handling multiple surfaces before serving food, worked without required beard coverings, and failed to label opened food items with open and expiration dates, contrary to facility food safety policies.
A resident requiring assistance with eating was addressed by a CNA as being fed 'like a baby' during mealtime. The resident, who is alert and oriented, expressed that being referred to in this manner is unwelcome and diminishes his sense of dignity. Facility leadership confirmed that such language is inappropriate and not in line with resident rights to dignity and respect.
A resident with quadriplegia and self-care deficits was found unable to access or use the call light, leaving them dependent on staff passing by and having to call out for assistance. The call light was out of reach and no alternative device was provided, despite the resident's documented need for staff support and the facility's policy requiring accessible means to request help.
A resident with hemiplegia who was fully dependent on staff for toileting was not provided incontinence care at least every two hours, as required by facility policy. The resident was observed sitting in a wheelchair with wet, soiled pants for nearly four hours after the last reported care, despite documentation and care plans indicating the need for frequent assistance.
Three residents with hemiplegia or contractures did not receive physician-ordered splints, braces, or soft foam devices as required by their care plans. One resident was unaware of a prescribed splint and was observed without it, another lacked a properly fitting orthotic for an extended period, and a third did not have a required foam device applied due to staff time constraints. Staff confirmed these devices were not consistently applied, contrary to facility policy and physician orders.
A resident with quadriplegia and acute respiratory failure experienced a significant decline in condition, including low blood pressure and oxygen saturation. Despite these changes, the facility failed to notify the physician, resulting in a delayed hospital transfer. The resident was later sent to the hospital in respiratory distress, suffered cardiac arrest, and expired. Interviews revealed a lack of communication and documentation by the nursing staff, contrary to the facility's policy.
A resident with quadriplegia and acute respiratory failure experienced a critical drop in blood pressure and oxygen level, but the LTC facility failed to conduct a comprehensive assessment or reassess vital signs. Despite being diaphoretic and in respiratory distress, the resident was not properly monitored, leading to their transfer to the hospital where they went into cardiac arrest and expired. Staff interviews revealed a lack of documentation and understanding of the importance of reassessment, contributing to the deficiency.
The facility did not display the [NAME] and [NAME] Retaliation Hotline poster, which informs residents of their rights, in accessible locations. Additionally, the facility failed to submit a monthly list of discharged residents to the [NAME] and [NAME] program. Staff were unaware of these requirements, potentially impacting all 42 residents.
A resident was found on a low air loss mattress set to static mode, contrary to the care plan requiring alternating pressure for wound healing. The ADON confirmed the static setting, which does not provide the necessary pressure relief. The DON stated that alternating pressure is essential for wound care, and the static setting should only be used temporarily. This failure to follow the care plan and manufacturer's instructions led to a deficiency in care.
The facility did not label medication bottles with the opened date, affecting three residents. An LPN noted the importance of the opened date for determining expiration and discard timing. The DON confirmed that nurses are responsible for labeling medications with the opened date, as per the facility's Medication Policy.
The facility failed to implement and complete pressure ulcer treatments and prevention interventions for three residents. One resident was not provided with a recommended low air loss mattress and had a soiled dressing. Another resident had missed wound care and lacked interventions for skin integrity. A third resident had discrepancies in the prescribed wound care treatments, with two different treatments signed off daily, neither matching the ordered regimen.
Failure to Protect Resident From Verbal Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact male resident with dementia and schizoaffective disorder from verbal abuse by a CNA. The resident, who had a BIMS score of 15 and a care plan goal to be treated with respect, dignity, and to reside free from mistreatment, reported that the CNA was always mad at him and turned whatever he said against him. On the day of the incident, the CNA believed the resident was speaking derogatorily about her in Spanish and became upset. According to the facility’s incident report and staff statements, the CNA approached the charge nurse in a loud, angry tone in the resident’s presence, yelling and screaming that the resident was talking about her. The incident report and the RN’s written statement document that the CNA continued yelling, cursing, and being verbally abusive toward the resident despite attempts by two nurses to calm her. The CNA raised her arm toward the resident and threatened him, stating that if he said one more thing about her in Spanish, she would “slap the sh*t out of” him and called him a “motherf**ker.” The RN reported she was concerned enough about potential physical aggression that she asked the resident to stand behind her while she tried to deescalate the situation. Other nurses and the administrator stated they had not previously heard the resident use racial slurs or curse staff, and the administrator confirmed that staff are expected to walk away, ignore, or respond calmly to negative resident comments and to continue to provide compassionate care. The facility’s abuse policy states it is the policy to prevent resident abuse, neglect, and mistreatment.
Delay in Emergency Response for Resident with Altered Mental Status After Fall
Penalty
Summary
The facility failed to follow its change in condition policy by not promptly calling advanced life support services (911) for a resident who was found with altered mental status and was verbally unresponsive. The resident, who had a history of atrial fibrillation, was on anticoagulant therapy, and was at high risk for falls, experienced an unwitnessed fall. Despite being found on the floor by a CNA and assessed by a nurse, the resident was not immediately sent to the hospital, even though facility staff acknowledged that residents on anticoagulants with unwitnessed falls should be evaluated for possible brain bleeds. The following morning, the resident was found unresponsive and not behaving as usual, with staff noting a significant change from his baseline mental status. The nurse notified the physician, who ordered a transfer to the hospital. However, instead of calling 911 as required by the facility's policy for medical emergencies involving unstable vital signs or unresponsiveness, staff called a basic life support (BLS) ambulance. Upon arrival, the BLS crew determined the resident's condition was critical and required advanced life support, prompting them to call 911 for an upgrade in care. Emergency medical services found the resident with decerebrate posturing, irregular bradypnea, and a Glasgow Coma Scale of 7, indicating severe neurological compromise. The resident was intubated and transferred to the ICU for ventilator management. Hospital records confirmed the resident had suffered rib fractures and was diagnosed with COVID and pneumonia. The delay in calling 911 and failure to follow the facility's change in condition policy resulted in a significant delay in appropriate emergency intervention for the resident.
Failure to Follow Food Safety and Sanitation Policies
Penalty
Summary
Dietary staff failed to adhere to the facility's Food Safety and Sanitation Policy by not changing gloves or sanitizing hands after handling multiple food ladles and other surfaces before directly scooping cornbread with the same gloved hand. This practice was observed during meal plating, and both the cook and dietary manager acknowledged that gloves should be changed after touching multiple surfaces to prevent cross contamination. Additionally, staff with beards were observed working in the kitchen without appropriate beard coverings, despite the policy requiring facial hair to be covered to prevent hair from contaminating food. Further, a bag of frozen peaches and a container of dried parsley were found in the kitchen without labels indicating the open and expiration dates. The dietary manager confirmed that labeling is necessary to ensure food is discarded appropriately and that all opened food items should be labeled with the open and expiration dates, as per facility policy. These failures in food handling, personal hygiene, and labeling practices have the potential to affect all residents on oral diets in the facility.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
A resident with hemiplegia and visual loss, who required partial to extensive assistance with eating, was observed being fed by a CNA in the main dining room. During the meal, the CNA told the resident that she had to feed him 'like a baby.' The Director of Nursing confirmed that such language is inappropriate and diminishes resident dignity, stating that staff should instead offer assistance respectfully. The CNA later acknowledged that she should not have made the comment and was aware of the expectation to address residents by their names or appropriate titles. The resident, who was alert and oriented, reported that staff sometimes refer to him as a baby, which he dislikes and feels undermines his sense of dignity and manhood. Facility documentation on resident rights states that residents must be treated with dignity and respect, and care should promote their quality of life.
Failure to Provide Accessible Call Light for Dependent Resident
Penalty
Summary
A resident with quadriplegia and documented self-care deficits was observed in bed without access to an appropriate call light. The call light string was hanging from the wall onto the nightstand, out of the resident's reach, and the resident reported being unable to use the call string due to his condition. The resident stated he had to wait until staff passed by his room and then yell for assistance, sometimes waiting a long time for help with activities of daily living. The care plan indicated the resident was dependent on staff for self-care due to contractures and quadriplegia, and the facility's policy required providing an alternative means to call for assistance if the call light was not functional. No other devices for calling staff were present in the resident's room at the time of observation.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A resident with hemiplegia and total dependence on staff for toileting hygiene was not provided incontinence care at least every two hours, as required by facility policy. The resident was documented as always incontinent and had a care plan indicating staff assistance with toileting throughout the day. On the day of observation, the resident was found sitting in a wheelchair with wet, soiled pants in the peri-area. The resident's roommate, who was alert and oriented, reported that incontinence care was last provided around 9:30am. The resident confirmed being changed in the morning but could not specify the time. The CNA assigned to the resident stated that incontinence care was provided at 10:00am and was scheduled again for 2:00pm, but acknowledged that sometimes the resident needed to be changed before the scheduled time. At 1:56pm, nearly four hours after the last reported care, the resident was still observed in the same wet condition. Facility policy requires incontinent residents to be checked and provided perineal and genital care every two hours, which was not followed in this instance.
Failure to Apply Splints and Orthotics as Ordered for Residents with Limited Mobility
Penalty
Summary
The facility failed to follow physician orders and care plans regarding the application of splints, braces, or soft foam devices for three residents with hemiplegia or contractures. One resident with hemiplegia affecting the left side had a physician order and care plan requiring a splint to the left upper extremity for 4-6 hours daily, but the resident reported not knowing about the splint and was observed without it on multiple occasions. Staff confirmed the splint was not applied because the resident was in bed and only restorative staff applied splints, which did not occur on the observed days. Another resident with hemiplegia and aphasia had a physician order and care plan for a left foot orthotic to be worn daily when out of bed, but the resident reported not having the orthotic for months due to improper fit. Staff were unaware of the issue until the survey, and the resident was observed without the device, with the foot turned inward. A third resident with hemiplegia had a physician order and care plan for a soft foam/sponge to be applied to the left hand, but was observed without it, and staff confirmed it was not applied due to time constraints. The facility's restorative policy requires individualized restorative care to maintain or improve residents' range of motion, but these interventions were not consistently implemented.
Failure to Notify Physician of Resident's Acute Change in Condition
Penalty
Summary
The facility failed to notify the physician of a resident's significant change in condition, which included a decrease in blood pressure and oxygen saturation. This oversight affected a resident with a history of quadriplegia, gastrostomy, and acute respiratory failure. The resident was found in a deteriorated state with symptoms such as diaphoresis, cool and clammy skin, and a respiratory rate of 60 breaths per minute. Despite these alarming signs, the physician was not notified, and the resident was only sent to the hospital 13 hours later, where they experienced cardiac arrest and subsequently expired. Interviews with the nursing staff revealed a lack of communication and documentation regarding the resident's change in condition. The nurse responsible for the resident during the overnight shift did not notify the physician despite noting a lower than usual blood pressure and oxygen level. The Director of Nursing emphasized the importance of recognizing changes in nonverbal residents and the necessity of immediate physician notification. However, this protocol was not followed, leading to a delay in appropriate medical intervention. The facility's policy on notifying physicians of significant changes in a resident's condition was not adhered to, as evidenced by the absence of documented communication with the physician. The resident's care plan required monitoring for signs of infection and notifying the physician, which was not executed. This failure to act on the resident's acute change in condition resulted in a critical delay in treatment, ultimately leading to the resident's death.
Failure to Reassess Vital Signs Leads to Resident's Death
Penalty
Summary
The facility failed to conduct a comprehensive assessment of a resident after experiencing a decrease in blood pressure and oxygen level, and did not reassess vital signs later in the shift. This deficiency affected a resident with quadriplegia, a gastrostomy, and acute respiratory failure, who was found diaphoretic with cool/clammy skin, a respiratory rate of 60 breaths per minute, and an oxygen level of 85%. Despite these critical signs, a blood pressure reading was not obtained, and the resident was transferred to the hospital in respiratory distress, where they went into cardiac arrest and expired. The report highlights that the nursing staff did not document any follow-up assessments or vital signs after the initial change in the resident's condition. Interviews with staff revealed that the resident was more sleepy than usual on the morning of the incident, but no further action was taken to monitor or reassess the resident's condition. The nurse on duty during the night shift noted a lower than normal blood pressure and oxygen level but did not document a reassessment or notify a physician, citing a lack of understanding of the importance of documenting reassessments. The Director of Nursing and Nurse Practitioner both emphasized the importance of reassessing abnormal vital signs and notifying a physician, especially for residents with communication barriers and chronic conditions. The facility's policies on patient monitoring and vital signs were not adhered to, as staff failed to proactively monitor and document changes in the resident's condition, leading to a delay in recognizing the severity of the situation and ultimately resulting in the resident's death.
Failure to Display Required Advocacy Information and Submit Discharge Lists
Penalty
Summary
The facility failed to display the [NAME] and [NAME] Retaliation Hotline poster in a public and accessible location, which informs residents of their rights regarding community transition and protection from retaliation. During an observation on 6/26/24, the surveyor, along with the Administrator (V1) and Admissions staff (V3), confirmed the absence of the poster on the first-floor bulletin board. Further inspections of the dining and activity rooms also revealed no signage of the required poster. Interviews with V1, V3, and Social Services (V8) indicated a lack of awareness about the necessity of posting this information for residents and family members. Additionally, the facility did not submit a monthly list of voluntary and involuntary discharge residents to the [NAME] and [NAME] program. V1 and V8 were unaware of this requirement, with V8 mentioning that only emails are sent to the agency when residents request community transfers. The facility's documentation, titled 'Health Care Council of Illinois,' outlines the requirement to post a list of pertinent state agencies and advocacy groups, yet this was not adhered to, potentially affecting all 42 residents in the facility.
Failure to Implement Effective Wound Care Interventions
Penalty
Summary
The facility failed to adhere to the Wound Care Plan for a resident, identified as R44, by not implementing effective interventions to prevent further skin integrity issues. On two separate occasions, R44 was observed lying on a low air loss mattress set to static mode, which does not provide the intended alternating pressure relief necessary for wound healing. The Assistant Director of Nursing (ADON) confirmed that the mattress was set to static, which is not suitable for continuous use as it does not offer the alternating pressure relief required for effective wound care. The Director of Nursing (DON) explained that the low air loss mattress is designed to promote wound healing through alternating pressure relief, and the static setting should only be used temporarily during position changes or care provision. The facility's Pressure Ulcer Prevention Protocol and the manufacturer's instructions both emphasize the importance of using pressure-reducing devices, such as alternating pressure mattresses, to prevent and manage pressure ulcers. The failure to utilize the mattress's alternating pressure setting as per the care plan and manufacturer's instructions contributed to the deficiency in care for R44.
Failure to Label Medications with Opened Date
Penalty
Summary
The facility failed to adhere to its Medication Policy by not labeling medication bottles with the opened date, affecting three residents. During an observation, it was found that a resident's Ketoconazole Shampoo 2%, another resident's levocarnitine Oral Solution, and a third resident's liquid Ondansetron were opened without any opened date on the label. A Licensed Practical Nurse (LPN) acknowledged the importance of the opened date for determining expiration and when to discard medications. The Director of Nursing (DON) confirmed that nurses are responsible for labeling medications with the opened date to ensure proper usage duration and adherence to expiration dates. The facility's Medication Policy requires that each prescribed medication label includes the date the medication was dispensed.
Failure to Implement Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to implement and complete pressure ulcer treatments and prevention interventions as ordered for three residents. One resident, R8, was observed lying on a regular mattress instead of a recommended low air loss mattress. R8 had a pressure ulcer on the sacrum, and the dressing was found to be soiled and unchanged since the previous day. The resident was not repositioned every two hours as required, and the care plan did not include an order for a specialty mattress, despite recommendations for a Group-2 mattress and frequent repositioning. Another resident, R3, had a history of cerebral infarction and vascular dementia, with two Stage 3 pressure wounds on the right foot. The treatment plan included specific dressing applications, but the Treatment Administration Record (TAR) showed missed wound care on several days in January 2024. Additionally, R3's care plan lacked interventions for skin integrity, and the facility's protocols for consistent treatment were not followed. The third resident, R6, had a Stage 4 pressure wound on the sacrum. The treatment orders included specific applications of calcium alginate with silver and foam dressing, but the TAR showed discrepancies in the prescribed treatments. Two different treatments were signed off daily, neither matching the ordered treatment, indicating a failure to adhere to the prescribed wound care regimen.
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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 Oak Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Park Oasis | 1.2 mi | ★★★★★ | 7 | 0 |
| Pearl Of Montclare, The | 1.6 mi | ★★★★★ | 3 | 0 |
| Bria Of Elmwood Park | 1.6 mi | ★★★★★ | 26 | 2 |
| West Suburban Medical Ctr | 1.7 mi | ★★★★★ | 2 | 0 |
| Central Nursing Home | 2 mi | ★★★★★ | 10 | 0 |
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