Berlin Nursing and Rehabilitation Center
9715 Healthway Drive, Berlin, MD 21811 · Worcester County · 165 certified beds · avg 94 residents/day · certified since Jul 1, 1980
Part of chain: FUNDAMENTAL HEALTHCARE (66 facilities, chain avg rating 2.4★)
2/5
Health inspection rating (on-site)
3
Serious findings on record
$232,065
Fines, last 3 years
2.88
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Sep 27, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Oct 20, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 23, 2025 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 19, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 27, 2023 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 20, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (71)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jul 23, 2025 | ▲ G · Actual harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Jul 23, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 23, 2025 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| Jul 23, 2025 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jul 23, 2025 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not let a resident or their legal representative see or buy copies of the resident's own records. |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Sep 27, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 27, 2023 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Sep 27, 2023 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Sep 27, 2023 | F · Potential for harm, facility-wide | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint |
| Sep 27, 2023 | F · Potential for harm, facility-wide | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. · from a complaint |
| Sep 27, 2023 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Sep 27, 2023 | E · Potential for harm, repeated | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Sep 27, 2023 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Sep 27, 2023 | E · Potential for harm, repeated | The facility did not make sure the resident's doctor reviewed their care and wrote, signed, and dated progress notes and orders at each required visit. · from a complaint |
| Sep 27, 2023 | E · Potential for harm, repeated | The facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint |
| Sep 27, 2023 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Sep 27, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Sep 27, 2023 | E · Potential for harm, repeated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint |
| Sep 27, 2023 | E · Potential for harm, repeated | The facility did not develop, carry out, or maintain an effective training program for all new and existing staff members. · from a complaint |
| Sep 27, 2023 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Sep 27, 2023 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Sep 27, 2023 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Sep 27, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Sep 27, 2023 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Sep 27, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Sep 27, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Sep 27, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Sep 27, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Sep 27, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Sep 27, 2023 | D · Potential for harm, one-off | The facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them. · from a complaint |
| Sep 27, 2023 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint |
| Jun 10, 2022 | E · Potential for harm, repeated | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Jun 10, 2022 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jun 10, 2022 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jun 10, 2022 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Jun 10, 2022 | D · Potential for harm, one-off | The facility did not honor residents' right to manage their own money and financial affairs. |
| Jun 10, 2022 | D · Potential for harm, one-off | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
| Jun 10, 2022 | D · Potential for harm, one-off | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| Jun 10, 2022 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jun 10, 2022 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jun 10, 2022 | D · Potential for harm, one-off | The facility did not honor residents' individual preferences, choices, values, and beliefs in their daily life and care. |
| Jun 10, 2022 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Jun 10, 2022 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jun 10, 2022 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jun 10, 2022 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jun 10, 2022 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jun 10, 2022 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Jun 10, 2022 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jun 10, 2022 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| Jun 10, 2022 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Jun 10, 2022 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 21, 2018 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Sep 21, 2018 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Sep 21, 2018 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Sep 21, 2018 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Sep 21, 2018 | D · Potential for harm, one-off | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (20 → 18).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2018 | 5 | 0 | D |
| 2022 | 20 | 0 | E |
| 2023 | 26 | 2 | J ▲ |
| 2025 | 20 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $232,065.
| Date | Type | Amount / length |
|---|---|---|
| Jul 23, 2025 | Fine | $21,348 |
| Sep 27, 2023 | Fine | $210,717 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Maryland avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.88 | 3.83 | 3.95 | bottom 2% in Maryland; bottom 10% in the U.S. |
| Registered Nurse hours | 0.47 | 0.83 | 0.69 | bottom 12% in Maryland; bottom 33% in the U.S. |
| Weekend total nurse staffing | 2.64 | 3.43 | 3.50 | bottom 5% in Maryland; bottom 14% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.34 | 0.63 | 0.48 | bottom 17% in Maryland; bottom 41% in the U.S. |
| Total nursing staff turnover (%) | 41.8 | 40.2 | 45.8 | bottom 49% in Maryland; top 41% in the U.S. |
| RN turnover (%) | 27.3 | 38.7 | 42.9 | top 23% in Maryland; top 24% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.12, RN 0.51, weekend 2.86. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: 2/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Maryland Long Term Care LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 03/18/2016 |
| Gozali, Angelica | Individual | W-2 Managing Employee | NOT APPLICABLE | 01/22/2018 |
| Gozali, Angelica | Individual | Corporate Officer | NOT APPLICABLE | 01/22/2018 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Snow Hill Rehabilitation & Healthcare Center | 15.2 mi | Snow Hill, MD | ★☆☆☆☆ | 2/5 | |
| Ocean Grove Post Acute | 17.9 mi | Millsboro, DE | ★★☆☆☆ | 2/5 | |
| Bay Harbor Post Acute Healthcare Center | 19.8 mi | Salisbury, MD | ★☆☆☆☆ | 1/5 | SFF |
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Facility data as of CMS processing date 2026-08-01. CCN 215126.