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 Berea Health And Rehabilitation during CMS and state inspections, most recent first.
A facility failed to develop and implement a baseline care plan for a resident requiring supplemental oxygen and Bi-pap machine use. The resident was admitted with a lumbar vertebra fracture and needed continuous oxygen at 5 LPM, but the facility did not create a care plan for this. The resident was found unresponsive with low oxygen saturation and later diagnosed with acute respiratory failure. Upon return, the facility again failed to include Bi-pap settings in the care plan, leading to the resident's death. The deficiency was identified under 42 CFR 483.21, and Immediate Jeopardy was noted.
A resident admitted for rehabilitation after a spinal fracture required a Bi-pap machine, as per physician's orders, but the facility failed to provide it upon readmission. The resident was found with low oxygen saturation and later died after being readmitted without the necessary equipment. The facility did not notify the physician about the equipment's absence, and staff interviews revealed a lack of communication and protocol adherence.
Failure to Implement Baseline Care Plan for Oxygen and Bi-pap Use
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident who was admitted with a diagnosis of lumbar vertebra fracture and required supplemental oxygen at 5 liters per minute (LPM) per nasal cannula. Despite the physician's orders, the facility did not create a care plan with detailed interventions for the resident's oxygen needs. This oversight resulted in the resident being found unresponsive with an oxygen saturation level of 41% on only 2 LPM of oxygen, leading to a transfer to the emergency room and a diagnosis of acute respiratory failure with hypercapnia. Upon the resident's return to the facility with new orders for a Bi-level Positive Airway Pressure (Bi-pap) machine and oxygen use, the facility again failed to ensure these were included in the care plan. The resident was found unresponsive a second time and was pronounced deceased shortly after. Interviews with facility staff revealed that the baseline care plan was supposed to be initiated by the admitting nurse, but this was not done for the resident's supplemental oxygen or Bi-pap settings. The facility's lack of an effective system to develop and implement baseline care plans that meet professional standards of quality care was identified as causing or likely to cause serious injury, impairment, or death. The deficiency was noted under 42 CFR 483.21 Comprehensive Resident Centered Care Plan, Baseline Care Plan, F655, and Immediate Jeopardy was identified and later validated by the State Survey Agency.
Failure to Provide Required Respiratory Care Leads to Resident's Death
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required a Bi-level Positive Airway Pressure (Bi-pap) machine upon readmission. The resident, admitted for rehabilitation after a spinal fracture, had a physician's order for continuous oxygen at five liters per minute. However, the resident was found with a low oxygen saturation level of 41% while on only two liters per minute of oxygen, leading to a hospital readmission for hypercapnic respiratory failure. Upon readmission to the facility, there was no documentation that the necessary Bi-pap machine was obtained, nor was the physician notified of its unavailability. The resident was readmitted to the facility without the required Bi-pap machine, despite the hospital discharge summary indicating its necessity. The facility's staff, including the Licensed Practical Nurse (LPN) on duty, failed to ensure the Bi-pap machine was available and did not notify the physician about the equipment's absence. The resident was found unresponsive and without respirations or a pulse, leading to their death shortly after readmission. The facility's investigation revealed that the respiratory supply company failed to deliver the Bi-pap machine, and the LPN did not follow the physician's order or notify the physician of the equipment's absence. Interviews with facility staff, including the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Medical Director, highlighted a lack of communication and adherence to protocols. The facility's policy required notifying the physician if necessary equipment was unavailable, which was not done. The Medical Director and the resident's long-term physician were not informed of the situation, and the resident was admitted under the care of the Medical Director without proper notification. The failure to provide the ordered respiratory care and notify the physician of the equipment's absence contributed to the resident's death.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 37 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Berea
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Terrace Nursing And Rehabilitation Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Kenwood Health And Rehabilitation Center | 9.9 mi | ★★★★★ | 0 | 0 |
| Madison Health And Rehabilitation Center | 9.9 mi | ★★★★★ | 1 | 0 |
| Telford Terrace | 11.5 mi | ★★★★★ | 3 | 0 |
| Rockcastle Health & Rehabilitation Center | 15.3 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.