Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Berkshire Rehabilitation & Skilled Care Center during CMS and state inspections, most recent first.
A CNA failed to treat a severely cognitively impaired resident with dignity and respect while redirecting the resident near the nurses' station. Witnesses reported the CNA used demeaning language such as "you're nasty" and "you're gross," and placed a hand on the resident's chest while telling the resident to move away. The resident had Parkinson's disease, schizophrenia, and a BIMS score indicating severe cognitive impairment, and the DON confirmed the interaction was not respectful or professional.
Failure to immediately report abuse and resident altercation allegations: Staff did not promptly notify administration after an LPN witnessed possible verbal and physical abuse between a CNA and a resident, instead leaving a note that was not found until days later. Staff also delayed reporting a resident-to-resident physical altercation involving two residents, with the DON learning of it nearly five hours after it occurred, despite policy requiring immediate reporting.
Incomplete abuse investigation and inaccurate DPH reporting: The Facility failed to document a thorough investigation and timely final report after an allegation that one resident punched another resident in the nose. The HCFRS report listed the wrong time and witness information, while the investigation file showed the incident occurred earlier and included staff witness statements, but no documentation supported the alleged push by the other resident or an interview with the reported resident witness. The DON said she could not explain the discrepancies and reported the time based on when staff notified her.
RN Coverage Did Not Meet Required 8 Consecutive Hours: The facility failed to ensure an RN worked 8 consecutive hours daily. Record review showed multiple days with no documented 8-hour RN coverage, including days when the scheduled RN called out or worked only partial shifts. The Scheduler said she was aware an RN had to be present daily but did not know the RN had to work a specific number of consecutive hours, and HR confirmed the DON worked only 4 hours on one of the affected days.
Kitchen sanitation and food storage deficiencies were observed in the main kitchen. A dish room fan had copious dust while blowing over clean pots and pans, an ice machine had white residue with a scoop stored on top of it, and the reach-in refrigerator contained raw chicken above undated raw hamburger plus unlabeled, undated juice. Surveyors also observed dust and dried debris on a clean dish rack and wall, dust on a storage rack and window, dried drips in the utensil area, and greasy/burnt debris on a rotary toaster; staff acknowledged several of these conditions.
Two residents with indwelling urinary catheters were observed with urinary drainage bags left uncovered and visible to others. One resident with severe cognitive impairment had a drainage bag hanging from a walker in the hallway and later in the room without a privacy cover, while another cognitively intact resident had a drainage bag on the floor at the end of the bed and visible from the hallway. Staff acknowledged the bags should have been covered to promote dignity and privacy.
Two residents had conflicting code status documents, with MOLST forms in the paper chart not matching EMR physician orders. For one resident, the MOLST showed full code while the EMR showed DNR/DNI; for the other, the EMR showed DNR while the MOLST showed attempt resuscitation. Staff said they used both the EMR and paper chart to determine code status, and one nurse stated she would attempt resuscitation based on the MOLST in the chart.
The facility failed to provide transfer notices and bed hold information, and failed to notify the Ombudsman, for four residents who were sent to the hospital for evaluation. The affected residents included one who was transferred after a 911 call, one with clammy skin and garbled speech, one after an unwitnessed fall with hip pain and swelling, and one after a physical altercation and later another transfer for SOB and wheezing. Records showed no documented evidence that the required notices were given to the resident or representative or that the Ombudsman was notified.
A resident with schizophrenia, anxiety disorder, bipolar disorder, and major depressive disorder had two episodes of suicidal ideation requiring ER psych eval and crisis team screening, but the facility did not submit a PASRR resident review to the State Mental Health Authority after either significant change in mental status. The record showed the resident voiced suicidal thoughts and a plan, and nursing notes documented emergency mental health interventions, yet no PASRR Level II referral was found.
A resident with psychiatric diagnoses was sent out twice for suicidal ideation, but the psychosocial care plan was not updated to reflect the new events or hospital recommendations. Another resident with vascular ulcers and DM had Dietitian-recommended supplements for wound healing, but the provider was not notified in a timely manner and the interventions were not documented as addressed for 11 days.
Failure to Provide Routine Dental Services: A resident with dementia, dysphagia, and adult failure to thrive had poor dentition, missing and jagged teeth, and was observed chewing on his/her tongue. The record showed dental care as needed and oral care interventions, but there was no evidence the resident was offered or received routine dental services, and the resident stated the facility would not let him/her see a dentist. The DON and Regional Nurse acknowledged the resident should have had routine dental services in place.
A nurse failed to follow infection control practices during wound care for a resident with arterial ulcers and DM by using the same soiled gloves throughout dressing removal, cleansing, ointment application, and new dressing placement without the required glove changes and hand hygiene. In a separate event, a resident with an indwelling urinary catheter had the drainage bag on the floor, and the nurse handled it without hand hygiene or the required gown and gloves under EBP.
A nurse physically abused a cognitively impaired resident by striking the resident's back, pulling their hair, and pinching their arm after the resident grabbed and squeezed the nurse's hand during an episode of restlessness. The incident, witnessed by another nurse and a resident, occurred despite facility policies prohibiting such actions, and the nurse admitted to reacting physically out of pain and uncertainty.
A resident with a history of substance use and mental health disorders, who was newly admitted and agitated, was physically restrained and verbally confronted by the DON and a CNA during an attempt to retrieve a bottle of pain medication from the resident's possession. The staff pinned the resident against a wall, blocked movement, pried open the resident's hand, and searched pockets, escalating the situation and violating abuse prevention policies.
Staff did not immediately report a witnessed physical altercation involving a resident and two staff members, as required by facility policy. The incident involved physically restraining and searching a resident with a history of substance use and mental health disorders. Additionally, required background checks were not completed prior to employment for a CNA and a SUD Counselor.
A resident with a history of substance use and mental health disorders was physically restrained and searched by the DON and a CNA after being found with prescription medication. The incident was reported to facility administration, but the required report to the Department of Public Health was delayed by six days due to a misunderstanding of reporting timelines, resulting in a deficiency for failure to report suspected abuse within the mandated timeframe.
A resident's care plan was not updated after a hospital visit resulted in a change from a suprapubic catheter to an indwelling urethral Foley catheter. The facility also failed to document the catheter size in the Physician's orders, as acknowledged by the DON.
A resident with vascular dementia receiving hospice care did not have physician-approved hospice recommendations for scheduled Morphine and Lorazepam implemented, leading to frequent PRN medication use for pain and anxiety. Facility staff failed to enter these orders into the electronic medical record, and a hospice care plan was not created.
A facility failed to provide appropriate respiratory care for a resident by not changing oxygen tubing as ordered and not following infection control measures. The resident, with a history of shortness of breath and emphysema, had oxygen tubing dated incorrectly, indicating it was not changed weekly as required. Additionally, the tubing was found on the floor instead of stored in a clean bag, violating facility policy.
A facility failed to develop a comprehensive Trauma Informed Care Plan for a resident with PTSD. The facility's policy requires such a plan to be documented by Social Services with the IDT, but no evidence of this was found in the resident's medical record. A social worker confirmed that a care plan should be created for residents with PTSD, yet the review showed no reference to the resident's PTSD, triggers, or interventions.
A facility failed to provide necessary transfer documentation for a resident with schizophrenia and Parkinson's disease, who was transferred to the hospital for mental health evaluation. The required transfer packet, which should have included medical history and medication information, was not completed or sent, as confirmed by staff interviews.
Failure to Treat a Cognitively Impaired Resident with Dignity and Respect
Penalty
Summary
The Facility failed to ensure a severely cognitively impaired resident was treated with dignity and respect when a CNA interacted with the resident in a demeaning and derogatory manner during redirection. The resident had diagnoses including Parkinson's disease, schizophrenia, and unsteadiness on feet, and the Quarterly MDS dated 01/04/26 showed a BIMS score of 3 out of 15, indicating severe cognitive impairment. The resident's behavior care plan noted a history of wandering intrusively and aggression toward staff, and directed staff to redirect the resident in a calm manner, divert attention, and remove the resident from the situation as needed. Several staff members reported that while the resident wandered near the nurses' station and stood too close to the CNA, the CNA responded by using disrespectful language and physical contact. Witnesses stated the CNA told the resident, "You're nasty," "You're gross," and "get your nastiness away from me," while also holding up a hand and placing a hand on the resident's chest to move him/her away. Nurse #1 stated the resident did not appear to react to the contact or lose balance and walked away, and also stated she advised the CNA that the resident should have been redirected in a respectful and professional manner. The DON confirmed the investigation determined the CNA failed to treat the resident with dignity and respect during the interaction.
Failure to Immediately Report Abuse and Resident Altercation Allegations
Penalty
Summary
The facility failed to follow its Abuse, Neglect and Exploitation policy requiring allegations of abuse to be reported immediately to administration. On 01/24/26, Nurse #1 witnessed an incident involving possible verbal and physical abuse between CNA #1 and Resident #1, including the CNA pushing the resident and making derogatory statements. Instead of immediately notifying facility administration by phone, Nurse #1 wrote a note describing the event and slid it under the Nursing Supervisor's office door, where it was not discovered until 01/27/26. The DON stated she first learned of the allegation on 01/27/26 and confirmed the expectation was for all allegations of abuse to be reported immediately. The facility also failed to follow its Resident to Resident Altercation policy requiring suspected altercations to be reported immediately to a supervisor. On 04/28/26 around 3:45 P.M., Resident #3 punched Resident #2 in the face after Resident #2 approached Resident #3 in the hallway, resulting in a nosebleed and ED transfers for both residents. Although staff were aware of the altercation, they did not notify a supervisor immediately and instead reported it to the DON at about 8:30 P.M., nearly five hours later. The DON stated that facility policy requires all allegations of abuse, including resident-to-resident altercations, to be reported to administration immediately.
Incomplete abuse investigation and inaccurate DPH reporting
Penalty
Summary
The Facility failed to ensure that, after being notified on 04/28/26 of an allegation that Resident #3 punched Resident #2 in the nose, it obtained and maintained evidence of a thorough investigation and submitted a final investigation report to the Massachusetts Department of Public Health (DPH) within five working days. The Facility policy titled Abuse, Neglect and Exploitation required the Administrator to follow up with government agencies and report final investigation results within five working days, but the Facility did not have documentation showing that the final investigative findings were completed and submitted to DPH by 05/05/26. The HCFRS report submitted by the Facility stated that Resident #3 became angry with Resident #2 and punched him/her in the face at 8:30 P.M., causing a nosebleed, and identified Resident #4 as the only witness. However, the Facility’s investigation file contained incident documentation and witness statements showing the altercation occurred around 3:45 P.M., not 8:30 P.M., and identified two staff members as witnesses. The file did not contain documentation supporting that Resident #2 pushed Resident #3 was investigated, and there was no interview or written statement from Resident #4. During interview, the DON stated she was not sure why there were discrepancies between the investigation and what was reported to DPH, and said the time was reported as 8:30 P.M. because that was when staff notified her of the incident.
RN Coverage Did Not Meet Required 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) worked eight consecutive hours daily, as required. Review of the nursing schedule from 12/28/25 through 1/28/26 showed no documented evidence that an RN worked at least eight consecutive hours on Sunday 1/4/26, Saturday 1/10/26, Saturday 1/17/26, and Sunday 1/18/26. The PBJ Staffing Data Report CASPER Report 1705D form for Quarter 4 2025 indicated the facility triggered for excessively low weekend staffing. During interviews and record review on 1/29/26, the Scheduler stated she knew an RN had to be in the facility daily but was not aware there needed to be a specific number of consecutive hours. She reported there was no RN on Saturday 1/10/26, the scheduled RN for Saturday 1/17/26 called out and no RN worked that day, the RN on Sunday 1/18/26 worked from 10:40 A.M. to 4:15 P.M. for 5.5 hours, and the RN scheduled for Sunday 1/4/26 called out, with the DON listed from 7:00 P.M. to 11:00 P.M. for 4 hours and no other RN hours that day. HR later confirmed the DON worked 4 hours on Sunday 1/4/26. The Administrator stated the information reviewed with the Scheduler and HR Staff was correct and said the facility was in the process of onboarding nursing staff, with the facility location being a challenge.
Kitchen sanitation and food storage deficiencies
Penalty
Summary
The facility failed to maintain the main kitchen in a clean and sanitary manner while storing, preparing, and distributing resident food and beverages. The deficiency involved the dish room fan, which was observed with copious amounts of dust while running and blowing air over clean pots and pans and toward the clean end of the dish machine. The surveyor also observed a large clear scoop exposed on the outer top surface of the ice machine, and the inner left side and top of the ice machine had white residue. The Food Service Director stated the fan needed to be cleaned, the ice machine needed to be cleaned, and the scoop should not be stored on top of the ice machine because of potential contamination. During the initial kitchen tour, the surveyor also observed a pan of bagged raw chicken dated 1/27/26 stored above a sheet pan of undated raw hamburger in the reach-in refrigerator, along with three pitchers of unlabeled, undated juice. The Food Service Director stated items should be labeled and dated. On the follow-up tour, the scoop was again observed exposed on top of the ice machine, and Dietary Aide #1 stated it should be stored in its designated wall holder because it was open to air and potential infection. Dietary Aide #1 also stated the juice should have been labeled with contents and date. Additional sanitation concerns were observed in the dish room and cook's preparation area. Visible dust and dried debris were present on a dish rack and on the wall behind the rack that housed clean dishware, and Dietary Aide #1 said she could not recall the last time the dish rack had been cleaned and that it was not on the cleaning schedule. The storage rack above the cook's preparation area had visible dust, the area where numerous tongs were stored had multiple white/tan dried drips, the window above the preparation area had large dust accumulation, and the rotary toaster below the window had greasy black debris and burnt black debris on the rotating rack. Dietary Aide #1 said she could see the black debris on the toaster but was not sure who should clean it. The Administrator was informed of the kitchen sanitation concerns and stated he understood them.
Failure to Maintain Privacy for Visible Urinary Drainage Bags
Penalty
Summary
The facility failed to ensure dignity and privacy for two residents with urinary drainage bags by not using privacy covers. The facility policy titled Urinary Drainage Bag Policy stated that urinary drainage bags should be kept in privacy bags to maintain resident dignity and privacy. Resident #15, admitted with diagnoses including benign prostatic hyperplasia and urinary retention, had severe cognitive impairment, required substantial to maximum assistance with toileting, and used an indwelling urinary catheter. His/her care plan included providing a privacy bag and promoting dignity. Surveyors observed Resident #15 multiple times with the urinary drainage bag hanging from the lower portion of the walker and the contents visible, including in the hallway near the nursing station and later in the room, with no privacy cover in place. Resident #55, admitted with diagnoses including need for assistance with personal care and neuromuscular dysfunction of the bladder, was cognitively intact, dependent on staff for dressing and toileting, and used an indwelling urinary catheter. Surveyors observed Resident #55 reclining in bed with the urinary drainage bag on the floor at the end of the bed and visible from the hallway, with no privacy cover in place. Nurse #2 stated both residents' urinary drainage bags should be covered, and the Regional Nurse stated privacy bags should be provided for all residents with urinary catheters to promote dignity and privacy.
Inconsistent code status records for two residents
Penalty
Summary
The facility failed to ensure advance directives were carried out in accordance with resident wishes for two residents whose code status information was inconsistent across records. The deficiency involved mismatched MOLST forms and physician orders, with staff relying on both the electronic medical record and the paper chart to determine code status in an emergency. The facility policy stated that MOLST forms are to be reviewed when there is a significant change in condition and that revisions or revocations must be documented in the medical record. For one resident, the record showed a MOLST signed by the HCP and NP indicating full code, while a later Comfort Care/Do Not Resuscitate order verification form signed by the HCP and APRN indicated DNR. The January 2026 physician order summary listed the resident as DNR/DNI. During interview, nursing staff stated they would check either the EMR or the physical chart for code status, and when reviewing the paper chart they went directly to the MOLST form, which still indicated attempt resuscitation. Staff acknowledged the discrepancy between the MOLST in the paper chart and the DNR/DNI physician order in the EMR, and the Regional Nurse stated the mismatch could confuse staff and might lead to resuscitation of a resident who did not want it. For the second resident, the January 2026 physician order summary and EMR dashboard listed code status as DNR, but the MOLST form in the paper chart signed by the Guardian and NP indicated attempt resuscitation. A separate transfer DNR order form in the chart indicated DNR and was not signed by the Guardian. Nursing staff stated they would look at whichever record was closest and, when reviewing the paper chart, said the MOLST form did not match the EMR and that they would attempt resuscitation based on the MOLST. The Regional Social Worker and Director of Social Services reviewed the records and stated they could not verify that the resident’s advance directives had been reviewed after the code status change, and later said legal review showed the Guardian did not have authority to make advance directive decisions at that time.
Failure to Provide Transfer Notices, Bed Hold Information, and Ombudsman Notification
Penalty
Summary
The facility failed to ensure that Notices of Transfer or Discharge and the Bed Hold policy were provided to residents or their resident representatives at the time of transfer or shortly thereafter, and failed to ensure that the Office of the State Long-Term Care Ombudsman was notified when residents were transferred to the hospital for evaluation. This deficiency involved four residents out of five applicable residents reviewed for hospitalizations, within a sample of 15 active records and one closed record. Resident #1, admitted in January 2014, was transferred to the hospital on 8/23/25 after 911 was called and the resident’s representative was notified; the resident returned on 8/29/25. Resident #10, admitted in June 2021, was sent to the hospital on 12/7/25 after becoming clammy, very cool to the touch, very white in color, and having garbled speech, and returned on 12/16/25. Resident #17, admitted in April 2016, was sent to the hospital on 1/22/26 after an unwitnessed fall with pain, redness, and swelling to the right hip, and returned on 1/23/26. Resident #57, admitted in June 2021, was transferred to the hospital on 12/18/25 after a physical altercation with another resident and later transferred again on 1/8/26 for shortness of breath and wheezing; the resident did not return after the second transfer. For each of these residents, the record contained no documented evidence that the Intent to Transfer and Bed Hold policy were provided to the resident or representative, and no documented evidence that the Ombudsman was notified.
Failure to Notify State Mental Health Authority After Significant Mental Health Changes
Penalty
Summary
The facility failed to notify the State Mental Health Authority for a resident review after a significant change in mental condition for one resident in the sample. The resident was admitted with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depressive disorder, and experienced two episodes of emergency mental health support related to suicidal ideation and thoughts of self-harm. On 9/11/25, the resident told staff he/she wanted to kill him/herself, was sent to the emergency room for a psychiatric evaluation, and told police he/she had items in the room to do it. A hospital discharge summary documented that the resident was seen for suicidal ideation. On 10/1/25, the resident again reported feeling down, depressed, and hopeless, stated he/she would cause harm to him/herself, and expressed suicidal thoughts with a plan but would not elaborate. Nursing documentation noted the resident was suicidal with a plan, and the on-call provider instructed staff to obtain a Section 12 for psychiatric evaluation. A subsequent hospital discharge summary documented the resident was seen for thoughts of suicide and screened by the crisis team. The medical record did not show documented evidence that the facility notified the State Mental Health Authority for a PASRR Level II resident review after either mental health event, and the Regional Social Worker confirmed that nothing had been sent to the PASRR office for either significant change.
Care Plans Not Updated After Suicidal Ideation and Dietitian Recommendations Delayed
Penalty
Summary
The facility failed to keep the person-centered care plan current for a resident with schizophrenia, anxiety disorder, bipolar disorder, and major depressive disorder after the resident voiced suicidal ideations and was sent to the emergency room for psychiatric evaluation on two occasions. Nursing and behavioral notes documented that the resident stated a desire to kill him/herself, reported feeling down, depressed, and hopeless, and told staff he/she had a plan for suicide. Hospital discharge summaries showed the resident was evaluated for suicidal ideation and thoughts of suicide, but the psychosocial well-being care plan, initiated in 2014 and revised in March 2025, still reflected anxiety and suicide ideation without documented updates after these emergency mental health events. For another resident admitted with atherosclerosis of the left leg with ulceration, type 2 DM with diabetic peripheral angiopathy, and adult failure to thrive, the Dietitian documented recommendations on the resident’s vascular wound that had not healed. The recommendations included L-arginine powder with zinc and vitamin C to support wound healing. The resident’s skin integrity care plan addressed the arterial ulcers and included antibiotic therapy and physician-ordered skin care and treatments, but the clinical record did not show documented evidence that the Dietitian’s recommendations were reviewed with the provider or otherwise acted on in a timely manner. The record review and staff interviews showed the provider was not updated until 11 days after the Dietitian’s recommendations, and the Regional Nurse stated the expectation was that nursing staff would notify the provider within 24 hours and document what occurred. The ADON also stated the recommendations were not linked or flagged in the 24-hour reports reviewed daily. The Regional Nurse identified this as a system breakdown and stated the recommendations for wound healing and malnutrition were not addressed until that day.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to assist one resident in obtaining routine dental services. Resident #42 was admitted in November 2024 with diagnoses including dementia, dysphagia, and adult failure to thrive, and had a BIMS score of 3 out of 15, indicating cognitive impairment. The facility policy stated that dental services would be provided as needed, staff would assist residents in obtaining routine and emergency dental care, and services would be provided by the resident’s dentist of choice or the facility’s consulting dentist. Resident #42’s active physician orders included dental care as needed, and the care plan identified poor dentition, dental consult as needed, and oral care every shift and after meals. Oral health evaluations dated 6/24/25, 10/22/25, and 1/23/26 indicated the resident required routine mouth care. On 1/28/26, the surveyor observed jagged and missing teeth and the resident chewing on his/her tongue; the resident stated he/she had teeth hanging down in his/her mouth and the facility would not let him/her see a dentist. The clinical record contained no evidence that the resident had been offered or received routine dental services while residing in the facility. During interviews, the Regional Nurse and DON stated residents should be seen by a dentist routinely, and the Regional Nurse later confirmed the resident had missing teeth, was biting his/her tongue, and definitely needed to see a dentist.
Infection Control Failures During Wound Care and Catheter Handling
Penalty
Summary
Infection control standards were not followed during wound care for a resident with arterial ulcers and diabetes. The resident was cognitively intact and had two arterial ulcers on the left lower extremity, with physician orders for daily wound treatments including cleansing, Dakin's solution, skin prep, antibiotic ointment, and dressings. During observation of the dressing change, the nurse removed soiled dressings but continued using the same gloves to cleanse the wounds, dry the skin, apply ointments, reach into medication cups, and place new dressings without changing gloves or performing hand hygiene at the required points in the procedure. The nurse used the same soiled gloves to handle the left ankle and left leg wounds, including applying skin prep and Dakin's-soaked packing strips from medication cups and then applying xeroform dressings and kerlix wrap. Only after completing the left leg treatment did the nurse remove gloves, perform hand hygiene, and don a new pair of gloves before continuing with the right lower leg wound care. The nurse later stated gloves should have been removed after old dressings were taken off and hand hygiene performed before applying new gloves and clean dressings, and acknowledged that not doing so could increase the risk for contamination and potential infection in the resident's wounds. In a separate observation, a resident with an indwelling urinary catheter had an uncovered urinary drainage bag lying on the floor with visible yellow contents. Enhanced barrier precautions signage was posted outside the room, but when the nurse entered to adjust the drainage bag, she did not perform hand hygiene or don a gown and gloves. The nurse picked up the drainage bag from the floor and attempted to secure it to the bed frame. The regional nurse stated the drainage bag and tubing should be off the floor and that the nurse should have performed hand hygiene and worn gown and gloves before adjusting the bag.
Nurse Engages in Physical Abuse of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a nurse engaged in physical abuse of a resident with moderate cognitive impairment. The incident took place as the nurse was assisting the resident, who had recently returned from the hospital with fractured ribs and was known to be restless and at risk for falls. The resident, who had diagnoses including vascular dementia, psychotic disorder with delusions, and generalized anxiety disorder, attempted to stand from his wheelchair and, during the interaction, grabbed and squeezed the nurse's hand, causing her pain. In response, the nurse struck the resident on the back, pulled the resident's hair, and pinched the resident's arm in an attempt to make the resident release her grip. These actions were witnessed by another nurse and an alert resident. The facility's policy on abuse, neglect, and exploitation, implemented in February 2023, explicitly prohibits physical abuse, including hitting, slapping, and pulling hair. Despite this policy, the nurse admitted to engaging in a physical altercation with the resident, stating that she reacted out of pain and uncertainty about how to de-escalate the situation. The incident was reported through the Health Care Facility Reporting System, and witness statements confirmed the physical actions taken by the nurse, as well as the use of profanity and inappropriate comments in the presence of residents immediately following the event. The investigation found that the resident, who was moderately cognitively impaired, would likely have experienced pain, anger, and emotional distress as a result of being struck and having their hair pulled by a caregiver. The incident was substantiated as physical abuse by the facility's internal investigation, based on direct observations, staff and resident interviews, and review of the facility's abuse prevention policy.
Resident Subjected to Physical and Verbal Abuse During Medication Retrieval
Penalty
Summary
A newly admitted resident, who was unfamiliar with the facility and staff and had difficulty adjusting to the admission, was subjected to both verbal and physical abuse by the Director of Nurses (DON) and a Certified Nurse Aide (CNA). The incident occurred when the resident, who had arrived with a bag of medications and was agitated due to the unexpected nature of the admission, was observed taking pain medication from a bottle in his possession. When approached by staff, the resident refused to relinquish the medication, leading to an escalation of the situation. The DON, with the assistance of the CNA, physically restrained the resident by pinning him against the wall, blocking his exit, holding his arms, prying open his hand, and searching his pockets. Multiple staff interviews confirmed that the resident was held against the wall in an alcove across from the nurses' station, was visibly upset, and repeatedly resisted the staff's actions. The altercation was described as loud and chaotic, with both the DON and the resident yelling, and lasted several minutes. The actions taken by the DON and CNA were in direct violation of the facility's abuse prevention policy, which prohibits unreasonable confinement and abuse of any kind. The resident involved had a medical history that included alcohol dependence with alcohol-induced persisting amnesic disorder, opioid abuse, major depressive disorder, and post-traumatic stress disorder. At the time of the incident, the resident was alert, oriented, and able to make his needs known, though his Health Care Proxy was activated prior to admission. The report notes that, based on the reasonable person concept, the resident would likely have experienced psychosocial harm, fear, anxiety, or anger as a result of being restrained and searched by staff entrusted with his care.
Failure to Report Abuse Allegation and Complete Pre-Employment Screening
Penalty
Summary
Staff failed to implement and follow the facility's abuse policy regarding the immediate reporting of abuse allegations and employment screening requirements. On one occasion, several employees witnessed the DON and a CNA physically restrain a resident against a wall, search the resident's pockets, and pry open the resident's hand in an attempt to retrieve medication. Despite multiple staff witnessing this physical altercation, none reported the incident immediately to the Administrator or DON, and the event was not brought to their attention until four days later. The SUD Counselor, who witnessed the end of the altercation, acknowledged not reporting the incident until several days after it occurred, contrary to facility policy requiring immediate reporting of abuse allegations. The resident involved had a history of alcohol dependence with alcohol-induced persisting amnesic disorder, opioid abuse, major depressive disorder, and PTSD. The resident was alert, oriented, and able to make needs known, with an activated health care proxy prior to admission. During the incident, the resident was agitated, uncooperative, and resisted being held, repeatedly telling staff to leave them alone. The altercation ended after staff removed a lighter from the resident's pocket, and the resident was subsequently sent to the emergency department for evaluation due to combativeness and uncertainty about medication ingestion. Additionally, the facility failed to conduct required background checks prior to employment for two staff members. The CNA involved in the incident began working at the facility over two months before a CORI check was completed, and there was no documentation of a Massachusetts Nurse Aide Registry check for the SUD Counselor prior to employment. The Administrator confirmed that these checks should have been completed before the staff began working, as required by facility policy.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
On 05/05/25, facility administration was made aware of an allegation of physical abuse involving a resident and two staff members, the Director of Nurses (DON) and a Certified Nurse Aide (CNA). The incident, which occurred on 05/01/25, involved the DON and CNA physically restraining the resident, searching their pockets, and removing personal items after the resident was found with a bottle of prescription medication. The resident, who had a history of alcohol dependence, opioid abuse, major depressive disorder, and post-traumatic stress disorder, was described as alert and oriented, with an activated Health Care Proxy prior to admission. The incident was reported to the administrator both verbally and in writing by the Substance Use Disorder (SUD) Counselor on 05/05/25. Despite facility policy requiring that all allegations of abuse be reported to the state agency within two hours, the allegation was not reported to the Department of Public Health (DPH) until 05/11/25, six days after the administration was notified. The delay occurred because the current DON misunderstood the reporting requirements, believing she had five days to submit the allegation. The failure to report the suspected abuse within the required timeframe constituted a deficiency in the facility's compliance with abuse reporting regulations.
Failure to Update Care Plan for Catheter Change
Penalty
Summary
The facility failed to review and revise the care plan for a resident who had a change in urinary catheter type. The resident, admitted with a diagnosis of Neuromuscular Dysfunction of the Bladder, initially had a care plan for a suprapubic catheter. However, after a hospital visit, the suprapubic catheter was replaced with an indwelling urethral Foley catheter. Despite this significant change, the care plan was not updated to reflect the new catheter type. Additionally, the October 2024 Physician's orders for the resident included instructions for Foley catheter care but did not specify the size of the Foley catheter or the retention balloon. During an interview, the Director of Nursing acknowledged that the care plans should have been updated when the catheter type was changed, and the catheter size should have been documented in the Physician's orders.
Failure to Implement Hospice Care Recommendations
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for a resident receiving hospice care. The resident, who was admitted with vascular dementia and severe cognitive impairment, was dependent on staff for all activities of daily living and was receiving hospice care services. Despite hospice recommendations for scheduled pain and anxiety management, the facility did not implement the physician-approved orders for scheduled administration of Morphine and Lorazepam, which were intended to manage the resident's pain and anxiety effectively. The hospice care narrative notes recommended scheduling Morphine 0.25 ml and Lorazepam 0.5 mg twice daily, in addition to existing PRN orders. However, the facility's records showed no evidence that these recommendations were reviewed, accepted, or declined, nor were they implemented in the resident's care plan. The medication administration records indicated that the resident frequently required PRN doses of Morphine and Lorazepam for pain and anxiety, suggesting inadequate management of these symptoms due to the lack of scheduled medication administration. Interviews with facility staff revealed a breakdown in communication and process. The MDS Nurse acknowledged the absence of a hospice care plan in the resident's medical record and admitted that it should have been created following the significant change assessment. The Staff Development Coordinator confirmed that the hospice recommendations had been approved by the provider but were not entered into the electronic medical record. The Director of Nursing recognized the oversight and noted that the hospice nurse, who visited weekly, should have identified the failure to implement the recommendations.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not changing the oxygen tubing as ordered by the physician and not following infection control measures. The resident, who was admitted with diagnoses including shortness of breath, dependence on supplemental oxygen, and emphysema, had a physician's order for oxygen via nasal cannula at two liters per minute and to change the oxygen tubing every Sunday during the 11-7 shift. However, the tubing was observed to be dated 9/23/24, indicating it had not been changed as per the order, despite being signed off in the treatment administration record as changed on 9/29/24. Additionally, the facility did not adhere to infection control protocols regarding the handling and storage of the oxygen tubing. The surveyor observed the oxygen tubing and nasal cannula on the floor under the resident's bed and wheelchair, rather than stored in a clean plastic bag as required by the facility's policy. Nurse #1 confirmed that the tubing should not be on the floor and acknowledged the absence of a plastic storage bag in the resident's room, as well as the discrepancy in the tubing change date.
Failure to Develop Trauma Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive Trauma Informed Care Plan for a resident with a history of Post Traumatic Stress Disorder (PTSD). The facility's policy requires that a trauma informed care plan be documented in the resident's medical record by Social Services in conjunction with the Interdisciplinary Team (IDT). However, upon review of the resident's medical record, there was no documented evidence of a comprehensive care plan addressing the resident's PTSD. During an interview, a social worker acknowledged that an initial baseline care plan should be completed upon admission and that a diagnosis of PTSD should be noted on the mood care plan. The social worker further stated that if a resident had active symptoms of PTSD, a specific care plan should be created. Despite this, the review of the resident's care plans revealed no reference to the history of PTSD, possible triggers, or any individualized interventions.
Failure to Provide Required Transfer Documentation
Penalty
Summary
The facility failed to ensure that the required transfer documentation was completed and communicated appropriately when transferring a resident to the emergency room. Specifically, the facility did not provide a transfer packet containing essential information such as contact details, physician orders, nursing assessments, medication lists, and other relevant medical information for a resident who was transferred under a Section 12 order for mental health evaluation. This omission put the resident at risk for complications and adverse events upon transfer to the hospital. The resident involved had diagnoses of schizophrenia and Parkinson's disease and was found in a state that necessitated transfer to the hospital. Despite the facility's policy requiring a comprehensive transfer packet, there was no documented evidence that such a packet was completed or sent with the resident. Interviews with facility staff, including a nurse and the Assistant Director of Nursing, confirmed that the transfer packet was not located, and they could not verify that the necessary information was provided to the receiving facility.
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.
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What surveyors actually found near you
We read the 129 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 Sandisfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Geer Nursing And Rehabilitation | 12.5 mi | ★★★★★ | 0 | 0 |
| Timberlyn Heights Nursing And Rehabilitation | 13.1 mi | ★★★★★ | 1 | 0 |
| Fairview Commons Nursing & Rehabilitation Center | 13.7 mi | ★★★★★ | 0 | 0 |
| Lee Healthcare | 15.7 mi | ★★★★★ | 17 | 0 |
| Noble Horizons | 17.1 mi | ★★★★★ | 30 | 1 |
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.