Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Berlin Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident was not protected from a significant medication error due to a failure in the medication administration process.
Surveyors found three opened, unlabeled bags of bread and three unlabeled containers of seasoning base in the kitchen. The Dietary Manager confirmed that the bread should have been labeled and that two containers held chicken base transferred from a larger container. This failure to properly store and label food items did not meet professional standards.
Surveyors found that the facility did not develop or implement complete care plans for three residents with complex needs, including dialysis, constipation, diabetes, depression, chronic pain, anticoagulant use, and contractures. Key health conditions and therapy recommendations were omitted from care plans, and these omissions were confirmed through interviews and record reviews. The DON acknowledged that these care needs should have been addressed in the care plans.
Surveyors identified that staff failed to document medication administration in the MAR at the time medications were given, with multiple instances of late charting for several residents. In addition, a resident's nursing note was incorrectly filed under another individual's record, resulting in incomplete documentation during a hospital transfer. The DON and NHA confirmed these documentation lapses and acknowledged that they did not meet facility policy requirements.
Surveyors identified that several residents did not receive accurate MDS assessments, including incorrect coding of hearing loss, falls, and urinary continence. For example, a resident with severe hearing impairment was assessed as having only moderate loss, and two residents who experienced falls were not properly coded for these events. Another resident with a Foley catheter was incorrectly coded as occasionally incontinent. These discrepancies were confirmed by facility staff during the survey.
Two residents experienced physical abuse by GNAs, including being pushed and sustaining injuries. In both cases, the facility substantiated the abuse through investigation and interviews, but failed to report one of the incidents to the Maryland Board of Nursing as required by policy and regulation.
A resident with an indwelling Foley catheter was observed with a visible, uncovered drainage bag attached to the bed frame, despite a physician order and facility policy requiring a privacy barrier. The DON confirmed that nursing staff were responsible for ensuring privacy covers were used, but this was not done at the time of the surveyor's observation.
A resident did not receive scheduled showers as ordered, with records showing only one shower provided over several months. The resident's POA raised concerns, and review of POC documentation confirmed the lack of showers and no evidence of refusals. The DON verified that neither refusals nor missed showers were documented, and the care plan did not address refusals.
A resident's legal representative repeatedly requested the complete medical record, but only partial records were provided on two occasions. Facility staff could not confirm that the full record was ever sent, and documentation to verify transmission was lacking.
A resident admitted with Atherosclerotic Heart Disease, Dementia, and End Stage Renal Disease, and receiving hemodialysis three times weekly, did not have a Baseline care plan developed or provided within 48 hours of admission as required. The DON confirmed the absence of the care plan in the clinical record.
Surveyors identified that two residents did not have their care plans properly reviewed or revised to reflect current interventions, including one with a wound lacking specific care plan interventions and documentation, and another whose responsible party was not properly notified or documented for a care plan meeting. The DON and social worker confirmed these deficiencies in care plan management and documentation.
Two residents did not receive care in accordance with professional standards. One resident, after an unwitnessed fall resulting in a head laceration and wrist fracture, had no documented follow-up nursing care, including missing neuro and circulation checks. Another resident was left unattended, undressed, and calling for help, with soiled items left in the room and bathroom, and without privacy measures in place. The assigned GNA reported leaving the resident after a refusal of care and combative behavior.
A resident with dementia and end stage renal disease, dependent on staff for grooming, was repeatedly observed with unshaven facial hair due to staff being unaware of the care plan requirement for shaving assistance. The lack of communication in updating the resident's profile led to the omission of necessary care.
Two residents experienced deficiencies: one did not receive a physician order for splint use despite OT recommendations for contracture management, and another was transferred to the hospital without proper assessment or documentation of vital signs and without addressing a complaint of trouble breathing. The DON confirmed the lack of necessary orders and documentation.
A resident with documented bilateral hearing loss and moderate hearing difficulty, as assessed in the MDS, did not receive an audiology consultation or hearing aids since admission. The facility's only intervention was the use of a whiteboard for communication, and the Clinical Service Director confirmed that no audiology referral had been made.
Two residents requiring dialysis care did not receive proper monitoring and documentation as required by physician orders and facility policy. For one resident, vital signs and weights were often not recorded before and after dialysis, and communication sheets from the dialysis center were frequently missing or incomplete. For another resident, the clinical record lacked documentation of the type and location of the dialysis shunt, physician orders for shunt monitoring, and evidence of nursing assessment of the shunt site, despite policy requiring regular inspection.
A required annual performance review was not completed for a Geriatric Nursing Assistant, despite facility policy mandating yearly evaluations. The DON confirmed the omission after a review of personnel files.
A resident's monthly drug regimen reviews identified that physician orders for PRN pain medications lacked pain scale guidance and that a narcotic pain medication had not been used for 60 days, with recommendations for clarification and discontinuation made by the pharmacist. These recommendations were not addressed by the physician, and no documentation of response was found in the medical record.
Surveyors found that a CMA administered medication from a bottle of Senna Plus that was not labeled with the date it was opened, contrary to facility practice. Additionally, a medication cart was observed unlocked and unattended in a hallway, with staff later confirming it should have been secured according to policy.
Two residents with indwelling medical devices did not receive proper infection control measures as required by facility policy. One resident with multiple wounds and a dialysis catheter was not placed on Enhanced Barrier Precautions, and there were no signs or supplies for EBP at the room entry. Another resident with a urinary catheter had the drainage bag lying on the floor, contrary to infection control standards.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or omissions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Properly Store and Label Food Items
Penalty
Summary
During an initial kitchen tour, surveyors observed three opened, unlabeled bags of bread stored on a steel cart in the kitchen, as well as three 14-ounce containers of beef flavored base that were also unlabeled and stored with other seasonings. The Dietary Manager confirmed that the bread bags were expected to be labeled and that two of the containers actually contained chicken flavored base, which had been transferred from a larger container in the cooler. These observations indicated that the facility failed to properly store and label food items to maintain their integrity, as required by professional standards.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
Surveyors identified that the facility failed to develop and implement comprehensive care plans for several residents, as required. For one resident with a history of constipation and undergoing dialysis three times a week, neither condition was included in the care plan despite documented complaints of constipation and ongoing dialysis treatments. The omission was confirmed through interviews and record reviews, which showed that the care plan was only updated after the issue was identified by surveyors. Another resident reported ongoing constipation and chronic pain, with a medical history including Type II Diabetes, Major Depressive Disorder, and use of anticoagulant medication. Despite these significant health concerns and active medication orders for each, the care plan did not address constipation, anticoagulant use, depression, diabetes, or chronic pain. The DON acknowledged that these issues should have been included in the care plan, but review of the updated care plan showed that only constipation was added, leaving other conditions unaddressed. A third resident was observed with contractures of the left elbow and both hands, and medical records confirmed these diagnoses along with recommendations from occupational therapy for splinting and positioning. However, there was no evidence that a care plan had been formulated to address the contractures since admission, despite documentation of therapy recommendations and care plan meeting notes referencing therapy involvement. The DON confirmed the absence of a care plan for contractures and stated that therapy recommendations were expected to be discussed in meetings.
Failure to Ensure Timely and Accurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure timely and accurate documentation of medical records for several residents, as evidenced by interviews and record reviews. Multiple instances were identified where medications were administered but not documented in the Medication Administration Record (MAR) at the time of administration. For one resident, medications scheduled for 9 PM were consistently signed off as complete well after 11 PM, with notes indicating that charting was done late but medications were administered on time. The Director of Nursing confirmed that medications are expected to be administered and documented within a specific timeframe, and acknowledged that the documentation was not completed as required. Further review of other residents' MARs revealed similar patterns of late documentation. For another resident, both afternoon and evening medications, including insulin and other critical medications, were signed off several hours after the scheduled administration times, again with notes stating that charting was late. Another resident's MAR showed delayed documentation for antibiotics, with charting occurring hours after the scheduled dose. These findings were corroborated by the facility's own Medication Management Program Policy, which requires immediate documentation after medication administration. Additionally, a review of medical records for a resident who was admitted and then discharged to the hospital revealed a lack of appropriate nursing documentation. Only one progress note was found for the period in question, and a relevant nursing note was incorrectly filed under the record of the resident's spouse rather than the correct resident. Both the Nursing Home Administrator and the Director of Nursing confirmed the absence of proper documentation and acknowledged the error in record-keeping.
Failure to Ensure Accurate Resident Assessments
Penalty
Summary
The facility failed to ensure that residents received accurate and comprehensive assessments, as evidenced by multiple discrepancies found during interviews and record reviews. One resident with severe bilateral hearing loss, who could only communicate via a whiteboard, was incorrectly assessed on the Minimum Data Set (MDS) as having moderate hearing loss, despite documentation and staff interviews confirming a higher level of impairment. Another resident who experienced a fall was not accurately coded for this event on the quarterly MDS assessment, even though progress notes and care plans documented the fall. A third resident with an indwelling Foley catheter was discharged to the hospital, but the discharge MDS assessment inaccurately coded urinary continence as "occasionally incontinent" instead of "Not rated," which is the correct coding when a catheter is present. Additionally, a fourth resident who had a fall and was sent to the hospital was not coded for the fall on the subsequent quarterly MDS assessment, despite clinical records confirming the incident. In each case, the discrepancies were confirmed by facility staff, including the Director of Nursing and the MDS Coordinator, during interviews with surveyors. These findings demonstrate that the facility did not consistently ensure the accuracy of MDS assessments for residents, particularly in areas related to hearing loss, falls, and urinary continence. The inaccuracies were identified through direct review of medical records, care plans, and staff interviews, highlighting a pattern of incomplete or incorrect documentation in resident assessments.
Failure to Protect Residents from Abuse and Report to Licensing Board
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two separate incidents involving geriatric nursing assistants (GNAs) and residents. In the first incident, a resident reported being pushed by a GNA by the back of the neck, shoved onto the bed, and sustaining an arm injury. The investigation conducted by the acting DON confirmed the presence of a bruise consistent with the resident's account, and the GNA was found to have abused the resident. In the second incident, another resident accused a GNA of hitting their finger after the resident pointed at a meal tray and put their hand in the GNA's face. The facility's investigation substantiated that there was direct physical contact between the GNA and the resident, and the GNA admitted to pushing the resident's hand away. The incident was reported to local law enforcement, and the resident confirmed being physically abused. However, the facility did not file a required complaint with the Maryland Board of Nursing regarding the substantiated abuse by the GNA, as was mandated by facility policy and state regulations.
Failure to Maintain Resident Dignity by Not Covering Foley Catheter Drainage Bag
Penalty
Summary
Facility staff failed to ensure the dignity of a resident with an indwelling Foley catheter. During the initial facility tour, a surveyor observed that the resident's Foley catheter drainage bag was attached to the bed frame and was not covered with a privacy barrier, making the urine visible. The resident's electronic medical record indicated a physician order for both the indwelling Foley catheter and a privacy bag to be in place every shift. In an interview, the DON confirmed that the facility provided privacy barrier covers for Foley catheter drainage bags and that it was the nursing staff's responsibility to ensure these were used upon resident admission. The deficiency was identified when the resident was found without the required privacy barrier, despite facility policy and physician orders mandating its use.
Failure to Provide Scheduled Showers and Support Resident Self-Determination
Penalty
Summary
A deficiency was identified when a resident did not receive scheduled showers as ordered by their physician, with documentation showing only one shower provided over a period of more than three months. The resident's Power of Attorney reported concerns about the lack of routine showers. Review of the resident's physician orders confirmed a standing order for showers twice weekly on the day shift. Examination of the Point of Care (POC) documentation revealed that showers were not provided as scheduled, and there was no documentation indicating that the resident refused care or showers during this period. The Director of Nursing confirmed the lack of both shower provision and refusal documentation, and the resident's care plan did not address refusals of care or showers.
Failure to Provide Complete Medical Records Upon Request
Penalty
Summary
The facility failed to provide a complete set of medical records to a complainant who had requested them multiple times for a specific resident. Record reviews confirmed that only partial records were sent on two separate occasions, with 9 pages (including a cover page) faxed on one date and 14 pages (including a cover page) faxed on another. Despite repeated requests, including a formal letter requesting all medical records from the patient chart, there was no documentation or fax confirmation that the full medical record had ever been provided to the complainant. Interviews with facility staff revealed uncertainty regarding whether the complete medical record packet was ever sent. The medical records staff member was unable to confirm the transmission of the full records and needed IT assistance to retrieve email records, which were not immediately available. The DON later confirmed that only incoming emails had been retrieved, and there was no confirmation of outgoing emails to verify that the complete records were sent. As a result, the surveyor determined that the facility did not ensure timely and complete access to the resident's medical records as required.
Failure to Complete Baseline Care Plan for Hemodialysis Resident
Penalty
Summary
The facility failed to develop and implement a Baseline care plan within 48 hours of admission for a resident requiring hemodialysis treatments. Record review showed that the resident, admitted with diagnoses including Atherosclerotic Heart Disease, Dementia, and End Stage Renal Disease, did not have a Baseline care plan completed or provided to them or their responsible party, as required. The resident was receiving hemodialysis three times a week. During an interview, the DON confirmed that the Baseline care plan was missing from the clinical record and could not provide a reason for the omission.
Failure to Review and Revise Care Plans and Inadequate Documentation of Care Plan Meetings
Penalty
Summary
The facility failed to review and revise interdisciplinary care plans to accurately reflect interventions for residents, as evidenced by two cases. In the first case, a resident with a wound on the right thigh had been receiving daily dressing changes per physician order, but the care plan did not include specific interventions or approaches to manage the skin impairment. Additionally, the clinical record lacked a description or measurements of the wound, despite documentation by a nurse noting its presence and treatment. The Director of Nursing confirmed that the care plan was not updated to include the resident's actual skin impairment and that the clinical record did not contain a description of the affected area. In the second case, a resident's significant other reported not being invited to a care plan meeting following the resident's admission. The social worker confirmed that no care plan meeting had been scheduled and that invitations were typically sent within two weeks of admission, but there was no documentation indicating that the responsible party declined the invitation or that a meeting had occurred. The deficiency was identified when the surveyor found a lack of documentation in the medical record regarding the care plan meeting process for this resident.
Failure to Meet Professional Standards of Care and Ensure Resident Dignity
Penalty
Summary
The facility failed to ensure that care provided to two residents met professional standards of practice. For one resident, after an unwitnessed fall resulting in a forehead laceration and a left wrist fracture, there was no documented evidence of follow-up nursing care. The resident's medical record lacked documentation of neurological checks for the head injury, circulation checks for the fractured arm, and progress notes regarding the resident's condition following the fall and injuries. The Director of Nursing confirmed the absence of this required documentation during the surveyor's review. In a separate incident, another resident was observed unattended, lying naked in a high bed, calling for help, and holding onto the bed rail. A soiled disposable brief was found on the floor, and a feces-soiled washcloth was left in the bathroom sink with water running. The privacy curtain was not drawn, and no staff were present in the room for at least ten minutes. The assigned GNA later stated that the resident had refused care and become combative, so the GNA left the resident in that condition. The Unit Manager and Regional Clinical Services Director subsequently provided education to the GNA regarding safety, privacy, dignity, infection control, and handling of residents who refuse care.
Failure to Provide Grooming Assistance per Care Plan
Penalty
Summary
A deficiency was identified when a resident with diagnoses including atherosclerotic heart disease, dementia, and end stage renal disease, who was dependent on staff for grooming, was repeatedly observed with unshaven facial hair over several days. The resident stated that assistance was needed with shaving due to inability to perform the task independently. The resident's care plan, initiated months prior, documented limited ability to maintain grooming and specified that staff should provide assistance or full performance for facial hair care. Despite this care plan, a Geriatric Nursing Assistant (GNA) was unaware of the resident's need for shaving assistance and believed the resident was independent, only providing help upon request. This lack of awareness was traced to a failure to transfer the care plan intervention to the resident's profile, resulting in staff not being informed of the resident's grooming needs. The deficiency was confirmed through interviews and record review, as well as direct observation of the resident's unshaven condition.
Failure to Obtain Splint Orders and Inadequate Assessment Prior to Hospital Transfer
Penalty
Summary
The facility failed to obtain a physician order for the use of a splint and did not properly assess or address a resident's condition prior to hospital transfer. For one resident with contractures of the left elbow and both hands, observations revealed the absence of splints or braces despite occupational therapy recommendations for orthotic support and the use of towel rolls. The occupational therapist confirmed that recommendations were made and communicated verbally to staff, but no formal physician order was documented, and the Director of Nursing acknowledged the lack of orders to address the contractures. In a separate incident, another resident was transferred to the hospital after experiencing pain and trouble breathing. Documentation showed that only one progress note was written in the relevant timeframe, and there was no record of vital signs being obtained or documented prior to the transfer, despite facility expectations. While pain medication was administered, there was no documentation indicating that the complaint of trouble breathing was addressed. The Director of Nursing confirmed the absence of vital sign documentation and the lack of follow-up on the respiratory complaint.
Failure to Provide Audiology Services for Resident with Hearing Loss
Penalty
Summary
A resident with a diagnosis of unspecified bilateral hearing loss was observed to have significant difficulty hearing, requiring the use of a whiteboard for communication with staff. During interviews, the resident confirmed not having hearing aids and reported not having seen an audiologist since admission to the facility. Review of the resident's medical records and care plan confirmed the presence of hearing loss, with interventions limited to the use of a whiteboard for communication. Further review of the resident's Minimum Data Set (MDS) assessment indicated moderate hearing difficulty, yet there was no documentation of an audiology consultation since the resident's admission. The Clinical Service Director acknowledged that the facility had not ordered an audiology consult to assess the resident's hearing. This lack of referral and assessment resulted in the resident not receiving appropriate audiology services to address their hearing loss.
Failure to Ensure Proper Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for two residents requiring such care. For one resident receiving hemodialysis three times a week, there were multiple deficiencies in following physician orders and facility protocols. Orders required documentation of pre- and post-dialysis vital signs and weights, as well as the return and scanning of Dialysis Communication Sheets into the electronic medical record. However, vital signs and weights were frequently not documented, with staff often citing the resident's condition or absence for dialysis as reasons. Additionally, many Dialysis Communication Sheets were missing or not scanned into the system, and those that were available often lacked required information such as pre- and post-dialysis weights and blood pressures. For another resident with end stage renal disease and a dialysis shunt, the clinical record lacked essential information, including the type and location of the shunt, a physician's order to monitor the shunt site for infection, and documentation of nursing staff monitoring the site. The care plan also did not include interventions or approaches related to shunt care, despite facility policy requiring shunt site inspection every shift for signs of infection. Staff interviews confirmed the absence of these critical elements in the resident's record, and the infection preventionist was unable to identify the shunt location or find relevant orders in the chart. These deficiencies were identified through record reviews and staff interviews, which revealed that the facility did not consistently follow its own policies or physician orders regarding dialysis care and monitoring. The lack of documentation and incomplete communication between the dialysis center and facility staff contributed to the failure to ensure proper care for residents undergoing dialysis.
Missed Annual Performance Review for Geriatric Nursing Assistant
Penalty
Summary
Facility staff failed to conduct a required annual performance review for one Geriatric Nursing Assistant who had been employed for over eight years. A review of five Geriatric Nursing Assistants' personnel files revealed that the performance review for the calendar year 2023 was not completed for this staff member. The Director of Nursing confirmed that, despite facility policy requiring annual reviews, the documentation for the required review was missing for the specified period. This deficiency was identified during a surveyor's review of personnel files and was confirmed through an interview with the Director of Nursing, who acknowledged the absence of the annual performance review for the affected staff member.
Failure to Address Pharmacist Drug Regimen Review Recommendations
Penalty
Summary
The facility failed to act on recommendations made by the pharmacist during monthly drug regimen reviews for a resident reviewed for unnecessary medication use. Specifically, the pharmacist identified that the resident had physician orders for two PRN pain medications, Tylenol and Tramadol, but the orders did not specify the pain scale rating to guide nursing staff on when to administer each medication. The pharmacist recommended that the physician clarify the orders to include the pain scale rating, but this recommendation was not addressed by the physician. Additionally, a subsequent pharmacist review noted that Tramadol PRN had not been used in the past 60 days and recommended discontinuing the medication to reduce unnecessary drug storage and associated risks. This recommendation was also not acted upon by the physician. Interviews with the DON confirmed that both pharmacist recommendations were not addressed, and there was no documentation or physician response to the pharmacist's reports in the resident's medical record.
Failure to Properly Label and Secure Medications
Penalty
Summary
Surveyor observations and staff interviews revealed that the facility failed to ensure proper labeling and storage of drugs and biologicals, as well as secure medication storage. During medication administration on the 300 unit, a Certified Medication Aide (CMA) was observed using a bottle of Senna Plus (sennosides-docusate sodium) that was not labeled with the date it was opened, despite the facility's practice requiring such labeling. The bottle was already opened and approximately half empty at the time of observation. The CMA confirmed that bottles should be dated when opened and proceeded to label the bottle after the surveyor's inquiry. The Regional Nurse Consultant, Licensed Nursing Home Administrator, and Director of Nursing were all notified of this finding. Additionally, a medication cart was found unlocked and unattended in a hallway, with all drawers accessible and no staff present nearby. A Geriatric Nursing Assistant (GNA) later locked the cart, stating the responsible nurse was assessing a patient elsewhere. The nurse later confirmed she had left the cart unlocked because she intended to return shortly, and the Director of Nursing acknowledged that the cart should have been locked when not in the nurse's view. Review of facility policy confirmed that medication carts are required to be locked when not in use and in direct line of sight.
Failure to Implement and Follow Infection Control Procedures for Residents with Indwelling Devices
Penalty
Summary
The facility failed to follow its own infection prevention and control policies and procedures, resulting in lapses in infection control for two residents. One resident with multiple wounds on the right foot, including a recent diagnosis of cellulitis and a dialysis catheter in the chest, was not placed on Enhanced Barrier Precautions (EBP) as required by facility policy. There were no EBP signs or infection control supplies at the entryway to the resident's room, and no order for EBP was present in the medical record at the time of observation and review. The infection control preventionist confirmed that residents with wounds and indwelling medical devices, such as central lines, should be on EBP, and the Director of Nursing agreed that EBP should have been implemented for this resident. Another resident with an indwelling urinary catheter and a history of urinary tract infections was observed with the catheter drainage bag lying flat and face down on the floor, rather than being properly hung on the bed. The Director of Nursing acknowledged that the drainage bag should not be on the floor, as this practice is inconsistent with infection control standards and increases the risk of contamination. Review of the facility's reference materials confirmed that catheter drainage bags should not be placed on the floor to prevent infection.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Berlin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Snow Hill Rehabilitation & Healthcare Center | 15.2 mi | ★★★★★ | 6 | 0 |
| Ocean Grove Post Acute | 17.9 mi | ★★★★★ | 1 | 0 |
| Bay Harbor Post Acute Healthcare Center | 19.8 mi | ★★★★★ | 15 | 2 |
| Cadia Rehabilitation Renaissance | 20.2 mi | ★★★★★ | 11 | 0 |
| Deer's Head Center | 21.1 mi | ★★★★★ | 10 | 0 |
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