Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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 Retirement Home,the during CMS and state inspections, most recent first.
The facility failed to maintain accurate medical records for two residents, resulting in incomplete documentation of skin and wound assessments. One resident's weekly skin checks and wound measurements were not properly recorded, while another resident's treatment lacked a documented physician's order. Interviews with nursing staff confirmed these documentation lapses.
The facility failed to implement a water management program to minimize the risk of Legionella and other pathogens in its water systems. Despite having policies in place, no documented program or water assessments were conducted. Both the Maintenance Director and Administrator confirmed the absence of an implemented program.
The facility failed to ensure care plans were reviewed and revised with the IDT for two residents. One resident's fall care plan was not updated to reflect the discontinuation of a leg brace, and another resident's ADL care plan inaccurately stated independence in ambulation despite requiring supervision and assistance.
The facility failed to provide RN services for at least eight consecutive hours a day, resulting in approximately 39 hours without RN coverage. This was confirmed through staffing data, punch cards, and interviews with the Administrator and Scheduling Coordinator.
The facility staff failed to inform a resident and their representatives about potential liability for payment for non-covered services, including the estimated cost of these services. The SNFABN form did not include the cost of rehab services, and the Administrator confirmed that the cost indicated was only for room and board.
The facility failed to accurately code the MDS for a resident regarding anticoagulation, antiplatelet, and hypoglycemic medication use. The resident was not on anticoagulants due to a gastrointestinal bleed, but the MDS indicated otherwise. Additionally, the resident was on clopidogrel and metformin, which were not correctly reflected in the MDS.
Deficiencies in Documentation of Skin and Wound Assessments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in documentation related to skin and wound assessments. For one resident, the facility did not document the completion of weekly skin assessments as required by the physician's orders. Additionally, the treatment administration record (TAR) showed that while the application of Silvadene ointment was signed off daily, the nursing staff only documented descriptions of the affected areas three times during the month, without including necessary measurements. This lack of documentation extended to the weekly skin checks, which were not recorded for several dates in January. For another resident, the facility initiated a treatment for a skin breakdown on the left buttock, but failed to document a physician's order for the treatment in the medical record. Although the TAR indicated that weekly skin checks were completed, there was no documentation of measurements or descriptions of the wound. Interviews with the Assistant Director of Nurses (ADON) and the Director of Nurses (DON) confirmed that the expected documentation was not completed, and the ADON admitted to not writing a physician's order for the treatment despite obtaining a verbal order.
Failure to Implement Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to implement a water management program to minimize the risk of Legionella and other opportunistic pathogens in its building water systems. Despite having policies in place since 9/2018, the facility did not have a documented water management program, nor did it conduct any water assessments or implement measures to control the introduction and spread of Legionella. The Maintenance Director, who started working at the facility four months ago, confirmed that no water management program had been initiated or documented. During an interview, the Administrator acknowledged that the facility had not implemented its water management program to monitor for Legionella. The Administrator, who started at the facility in December 2023, was also unable to locate any documentation of a water management program. This lack of implementation and documentation led to the deficiency noted in the report.
Failure to Update and Review Care Plans
Penalty
Summary
The facility failed to ensure care plans were reviewed and revised with the interdisciplinary team (IDT) as required for two residents. Resident #5, who was admitted with diagnoses including anxiety, depression, heart failure, and paroxysmal atrial fibrillation, had a fall care plan that was not updated to reflect that the resident had not worn a leg brace for over a year. Despite the care plan conference summary indicating a review, observations and staff interviews confirmed the resident was not using the brace, highlighting a lapse in updating the care plan after each Minimum Data Set (MDS) assessment. Resident #15, admitted with diagnoses including dementia and a history of falling, had an Activities of Daily Living (ADL) care plan that inaccurately stated the resident was independent in ambulation with a rolling walker. Observations and staff interviews revealed that the resident required supervision and assistance, including the use of a gait belt, while ambulating. The care plan had not been revised to reflect the resident's current needs, indicating a failure to update the care plan to match the resident's actual condition and requirements.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. Specifically, there was no RN coverage for approximately 39 hours, from 11:15 P.M. on 10/20/23 until 2:45 P.M. on 10/22/23. This deficiency was identified through a review of the PBJ Staffing Data Report for Quarter One 2024, nursing punch cards, and interviews with the Administrator and Scheduling Coordinator. The Administrator confirmed the lack of RN coverage on 10/21/23 and acknowledged awareness of the requirement for RN coverage. The Scheduling Coordinator also confirmed that there should be at least eight consecutive hours of RN services each day.
Failure to Inform Resident of Potential Liability for Non-Covered Services
Penalty
Summary
The facility staff failed to inform a resident and their representatives about potential liability for payment for non-covered services, including the estimated cost of these services. The Advanced Beneficiary Notice (SNFABN) form, which is intended to provide residents and their beneficiaries with information to decide if they wish to continue receiving skilled services that may not be covered by Medicare, did not include the cost of rehab services for the resident. During an interview, the Administrator confirmed that the cost indicated on the form was only for room and board and did not include skilled services such as rehab.
Inaccurate MDS Coding for Medications
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were coded accurately for one resident out of a total sample of 11 residents. Specifically, for Resident #5, the MDS was inaccurately coded regarding anticoagulation use, antiplatelet use, and hypoglycemic medication use. The resident, who was admitted with diagnoses including anxiety, depression, heart failure, and paroxysmal atrial fibrillation, had an MDS assessment indicating the use of anticoagulants, which was incorrect. The Medication Administration Record (MAR) for April 2024 did not show any anticoagulant medication prescribed or administered to the resident, and a nurse practitioner’s progress note confirmed the resident was unable to have anticoagulation due to a gastrointestinal bleed. Additionally, the MDS assessment failed to accurately reflect the resident's use of antiplatelet and hypoglycemic medications. The resident had a physician's order for clopidogrel (an antiplatelet medication) and metformin (a hypoglycemic medication), both of which were administered as per the MAR for April 2024. However, the MDS assessment incorrectly indicated that the resident was not on these medications. During an interview, the Director of Nursing (DON) acknowledged that the MDS was not coded correctly.
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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 Lawrence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| M I Nursing & Restorative Center | 0.5 mi | ★★★★★ | 30 | 0 |
| Cedar View Rehabilitation And Healthcare Center | 1 mi | ★★★★★ | 5 | 0 |
| Nevins Nursing & Rehabilitation Center | 1 mi | ★★★★★ | 13 | 0 |
| Royal Wood Mill Center | 1.5 mi | ★★★★★ | 4 | 0 |
| Prescott House | 2.5 mi | ★★★★★ | 22 | 0 |
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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.