Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Williamstown Commons Nursing & Rehab during CMS and state inspections, most recent first.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
Food Served at Unappetizing Temperatures and Quality: Residents reported poor taste, freshness, and portion size, and surveyors observed multiple lunch trays with hot foods served lukewarm or cold, bland items, and melted ice cream. A resident with dysphagia and a history of peritonsillar abscess said breakfast items were repeatedly served cold and unappetizing, and staff did not offer to warm them or provide an alternative.
Food service staff failed to follow sanitary food handling practices during tray line preparation. Two Dietary Aides with facial hair were observed without beard restraints, and one Dietary Aide left the tray line to answer the phone, handled a pen and notepad, and returned to the line without hand hygiene, contrary to facility policy and the FSD’s stated expectations.
A facility failed to keep catheter drainage bags and tubing off the floor for two residents with indwelling catheters, and an RN failed to perform hand hygiene at key points during med pass. The RN also handled meds after touching the computer with gloved hands and did not disinfect shared equipment, including a vitals machine, BP cuff, and stethoscope, between resident uses.
Enteral feeding was not administered according to the provider’s order for a resident with a feeding tube, dysphagia, dementia, and ESRD. A nurse gave two containers of Jevity 1.5 cal, with each container observed to contain 237 ml, even though the order specified 240 ml per bolus. The nurse acknowledged the resident received too much enteral nutrition, and the NP and DON noted monitoring for GI symptoms and residuals after the excess feeding.
Pain medication order not implemented for a resident with a fractured patella and ongoing pain. The resident, who was cognitively intact and had frequent pain affecting sleep and daily activities, reported that the MD said Naltrexone would be stopped and Morphine PRN would be ordered, but the change did not occur as discussed. Naltrexone continued to be given and was refused, while Morphine was not available when the resident requested stronger pain relief. The MAR, nurse fax, pharmacy record, and MD interview showed the Morphine script was delayed and not in place when expected.
The facility failed to keep accurate controlled substance records and failed to provide ordered pharmacy services for a resident with MDD and multiple psychiatric diagnoses. Controlled substance books had incomplete headings, torn index pages, missing Rx numbers and receipt dates, and transfers without the required second nurse signature; one Lorazepam entry also lacked documentation of destruction. A resident prescribed Auvelity BID had multiple missed doses because the medication was not available, was on order, or had run out, despite the DON, pharmacy, and nursing notes documenting the delays.
The facility's main kitchen was found to be unsanitary, with dried food debris on the stove and oven, and lime build-up on the dishwasher. The Food Service Director and Dietician admitted that the cleaning schedule was not followed due to staff being affected by COVID, with the last cleaning log dated months prior.
A facility failed to notify the State Mental Health Authority for a resident review after a significant change in mental condition. A resident with Schizoaffective Disorder and Dementia experienced increased agitation and paranoia, requiring emergency interventions. Despite this, the facility did not complete a necessary PASRR Level II screen to assess the need for additional support services, as required by their policy.
The facility failed to provide proper respiratory care for two residents, as surveyors found outdated oxygen tubing and improper storage of nebulizer equipment. One resident with COPD and respiratory failure had outdated oxygen tubing and an empty humidification bottle, while another resident with vascular dementia and pulmonary fibrosis had undated oxygen tubing. The Unit Manager confirmed the lapses in following professional standards for respiratory care.
A facility failed to limit the administration of PRN Ativan for a resident with mental health conditions to 14 days, as required by its policy. The resident received the medication multiple times without a stop date or reevaluation, which was confirmed by a Unit Manager during an interview.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Food Served at Unappetizing Temperatures and Quality
Penalty
Summary
The facility failed to ensure that food and drinks were palatable, attractive, and served at a safe and appetizing temperature for residents on three units. During the initial pool process, residents on Unit 1 and Unit 2 reported that the food was terrible, bland, not fresh, too small in portion, or not eaten because of poor taste and appearance. One resident said the bread on sandwiches did not look fresh, another said he or she did not receive extra food when requested, and another said the meals were so poor in taste that he or she was not eating them. The surveyor then requested test trays during lunch service on Units 1, 2, and 3. On Unit 3, the surveyor observed meal distribution and tested the tray after the last resident tray was served. The pureed veal with gravy measured 110 degrees Fahrenheit and was described as lukewarm, loose, and not holding its shape; pureed carrots measured 111 degrees Fahrenheit and were lukewarm; mashed potatoes with gravy measured 125 degrees Fahrenheit and were bland and not palatable; and strawberry ice cream measured 20 degrees Fahrenheit and was melted around the edges with a firmer center. A nurse stated she made strawberry milkshakes for residents because the ice cream was melted. On Unit 2, the test tray showed macaroni and cheese at 120 degrees Fahrenheit and stewed tomatoes at 95 degrees Fahrenheit. On Unit 1, the test tray showed veal cutlet with gravy at 90 degrees Fahrenheit, mashed potatoes with gravy at 100 degrees Fahrenheit and bland, and mixed vegetables at 85 degrees Fahrenheit. Resident #93, who had dysphagia and a history of peritonsillar abscess and was cognitively intact, reported that breakfast items such as scrambled eggs and potatoes were cold and unappetizing. The resident said the cold items were set aside, that staff did not offer to warm them, and that this had happened repeatedly for several weeks. The resident also said no alternative option was provided. The DON stated that if a resident did not eat a meal, staff should ask why and offer alternative food items or reheat the meal if the complaint was that it was too cold.
Food Service Staff Failed to Follow Sanitary Food Handling Practices
Penalty
Summary
The facility failed to ensure staff prepared, distributed, and served food in accordance with professional standards for food service safety. During observation of the kitchen tray line, two Dietary Aides with facial hair were observed on the tray line without beard protectors, despite the facility policy requiring hair nets and beard restraints when entering the main kitchen area. During the same observation, Dietary Aide #1 stepped away from the tray line to answer the phone, picked up a pen from the counter, wrote notes on a notepad, replaced the phone and pen, and returned to the tray line without performing hand hygiene. In interview, the Food Service Director stated staff with facial hair should wear beard protectors and that staff are required to wash their hands whenever they leave the tray line before returning. Dietary Aide #1 stated he stepped away from the tray line to answer the phone, wrote down an order, went to the walk-in freezer to gather items, and returned to finish placing items on trays without washing his hands.
Catheter Care, Hand Hygiene, and Shared Equipment Cleaning Failures
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for residents with indwelling urinary catheters and failed to ensure proper hand hygiene and disinfection of shared medical equipment during medication distribution and vital sign checks. The report identified two residents with urinary catheters, Resident #102 and Resident #58, whose catheter drainage bags and tubing were observed in contact with the floor. The report also documented that Nurse #1 did not perform hand hygiene at required points during medication pass and did not disinfect shared equipment between resident uses. Resident #102 was admitted in February 2026 with diagnoses including urinary retention and chronic kidney disease. The resident’s MDS indicated moderate cognitive impairment, renal insufficiency/renal failure/ESRD, and care plans documented an indwelling Foley catheter, dependence on staff for toileting, maximum assistance for hygiene, and maximum assistance for bed mobility. On 3/24/26 and again on 3/25/26, the resident was observed lying in bed with the catheter drainage bag attached to the bedframe and hanging onto the floor, with part of the bag lying on the floor. Staff interviewed about the observation stated that the drainage bag should not be touching the floor and identified it as an infection control concern. Resident #58 was admitted in January 2026 with diagnoses including dementia, bladder cancer, and acute urinary retention. The resident’s MDS showed severe cognitive impairment, dependence on staff for toileting and personal hygiene, assistance needed for transfers, and an indwelling catheter. The care plan directed staff to secure the catheter and keep the drainage bag and tubing below bladder level. On multiple observations, the resident was seated in a wheelchair with the urinary drainage bag and tubing resting on the floor, and during transport the tubing could be heard dragging on the carpet. Staff stated the resident was dependent with ADL care, often pulled on the catheter tubing, and that the bag and tubing on the floor were an infection control concern. During medication distribution, Nurse #1 was observed wearing gloves, touching the computer mouse, and then handling a pill from the medication cup with the same gloved hand. The nurse also discarded gloves without performing hand hygiene and later resumed medication pass without hand hygiene after glove removal. During vital sign collection, Nurse #1 used a vitals machine, BP cuff, and stethoscope for multiple residents without disinfecting the equipment between uses. The nurse stated she did not disinfect the shared equipment because she believed it was only needed for residents on precautions, and the UM stated the equipment should be disinfected after each resident use and before use on another resident.
Enteral Feeding Given in Excess of Physician Order
Penalty
Summary
The facility failed to ensure appropriate enteral feeding was provided for one resident with a feeding tube. Resident #2 was re-admitted with diagnoses including dysphagia following cerebral infarction, morbid obesity due to excess calories, dementia, and end-stage renal disease. The resident’s March 2026 order summary included NPO status and an enteral feeding order for Jevity 1.5 cal by gravity or bolus five times a day, with 240 ml to be administered each time and 60 ml of free water before and after bolus administration. The resident’s tube feeding care plan stated the resident was dependent with tube feeding and water flushes and referenced the physician’s current feeding orders. During observation on 3/26/26, Nurse #6 administered two containers of Jevity 1.5 cal, and each container was observed to contain 237 ml. In interview, Nurse #6 stated the resident was ordered to receive 240 ml of Jevity 1.5 cal and acknowledged the resident received too much enteral nutrition. The NP stated nurses were expected to follow provider orders and that the resident would be monitored for nausea, vomiting, abdominal pain, and residuals after receiving more than the ordered amount. The DON also stated the resident was being monitored for abdominal distention, abdominal discomfort, vomiting, and residual volume after receiving more than the physician-ordered volume.
Pain Medication Order Not Implemented
Penalty
Summary
The facility failed to ensure pain management was provided in accordance with the resident’s goals for care and preferences for one resident with a fractured left patella, right wrist sprain, anxiety disorder, and obesity. The resident was cognitively intact with a BIMS score of 15 and had frequent pain that occasionally affected sleep, frequently interfered with day-to-day activities, and was rated as 8 out of 10 on the MDS. The resident’s pain care plan and acute pain care plan both directed staff to administer pain medications per physician orders. The resident reported that on 3/13/26 the physician said Naltrexone would be discontinued and Morphine would be ordered as needed, but that this change did not occur as discussed. The resident stated Naltrexone continued to be given after that discussion, leading to refusal of the medication, and Morphine was not available when needed. The resident also reported at least one time when additional pain medication was desired beyond Acetaminophen, but Morphine was not available. The order summary showed Acetaminophen PRN, Naltrexone twice daily with instructions to hold while taking Morphine, and a Morphine PRN order that was not started until 3/26/26. MAR review showed Naltrexone doses were refused on multiple occasions and then placed on hold beginning with the evening dose on 3/17/26. A nurse faxed the physician on 3/16/26 stating there were no Morphine orders despite the resident’s report that the physician had said Morphine would be ordered and Naltrexone held. The physician stated he had intended to order Morphine PRN on 3/13/26 but sent the script to the wrong pharmacy, and the contracted pharmacy confirmed it did not receive a Morphine script until 3/24/26. The DON stated the expectation was that the nurse entered the physician’s orders into the EHR and that the Morphine order should have been implemented on 3/13/26.
Inaccurate controlled substance records and missed Auvelity doses
Penalty
Summary
The facility failed to maintain accurate controlled substance records for Unit Two. In three controlled substance books reviewed, many page headings were incomplete, several index pages were worn and torn with pieces missing, and multiple controlled medications were transferred to different pages by one nurse without the required second nurse signature. In one book, eight pages had no prescription numbers and no receipt dates documented for the medications. In another, a Lorazepam liquid entry showed the medication was removed from count to be destroyed, but there was no documentation that destruction occurred. Staff interviewed, including nurses and the DON, stated that the prescription number, date filled, complete page headings, destruction documentation, and two-nurse signatures were expected, but these entries were not completed. The facility also failed to provide ordered pharmaceutical services for Resident #80. The resident was admitted with diagnoses including major depressive disorder, anxiety disorder, obsessive-compulsive disorder, panic disorder, and trichotillomania, and the MDS showed the resident was cognitively intact with a BIMS score of 15. The resident reported that it took nearly three to four days after admission for all prescribed medications to be available, that home medications brought in by the partner were not allowed for use, and that Auvelity had also run out for one evening dose. The resident’s care plans identified risk for mood fluctuation and psychotropic medication use related to the psychiatric history, and the care plan directed staff to administer psychotropic medications as ordered. The order summary showed Auvelity was ordered as 1 tablet by mouth twice daily for MDD starting on 3/4/26. The MAR showed missed administrations on multiple occasions, including both scheduled doses on 3/4/26, the morning dose on 3/5/26 and 3/6/26, and the evening dose on 3/21/26. Progress notes documented that the medication was not available, was on order from the pharmacy, or was awaiting delivery, and the physician was aware. The pharmacist stated the medication had to be special ordered, that a 30-day supply was sent to the facility on 3/5/26, and that the medication should have been available for administration on 3/21/26 because it should not have run out after the initial delivery.
Unsanitary Kitchen Conditions Due to Lapsed Cleaning Schedule
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the main kitchen where resident food was prepared. During an observation, dried elbow noodles and food debris were found on the left side of the stove top, and there was built-up food debris and drippings on the stove. Additionally, the right side of the oven had dark grease markings and dried food debris. The dishwasher was observed to have large amounts of white lime build-up with drip-like markings on both sides. The Food Service Director (FSD) acknowledged these issues and mentioned that there was a cleaning schedule in place, but it had not been followed due to kitchen staff being affected by COVID. The FSD and Dietician confirmed that the cleaning schedule was not adhered to, as evidenced by the last documented cleaning log dated several months prior. They admitted that the kitchen should be cleaned every day, and staff should ensure their workspaces are clean and sanitary after each meal or when they are done in that work area. The lack of routine cleaning and sanitization led to the unsanitary conditions observed in the kitchen, which were not in compliance with professional standards for food preparation and safety.
Failure to Conduct PASRR After Significant Change in Condition
Penalty
Summary
The facility failed to notify the State Mental Health Authority for a resident review after a significant change in mental condition occurred for one resident. The resident, who was admitted with diagnoses including Schizoaffective Disorder and Dementia, experienced a significant change in condition marked by increased agitation and paranoia, leading to emergency mental health interventions. Despite these changes, the facility did not complete or request a Preadmission Screening and Resident Review Level II screen (PASRR), which is necessary to determine if the resident requires additional specialized support services. The facility's policy on Preadmission Screening and Resident Review (PASRR) requires a referral to the Department of Developmental Services or Department of Mental Health when a resident experiences a significant change in condition that may impact their PASRR disability status. However, the only PASRR completed for the resident was the initial one at admission, and no new assessment was conducted after the resident's condition worsened. Interviews with the social worker revealed that the team recognized the need for a new PASRR after the resident's significant change in condition, but it was not completed or submitted as required.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for two residents, as observed by surveyors. Resident #47, who was admitted with diagnoses including Chronic Obstructive Respiratory Disease and Respiratory Failure, was found with outdated oxygen tubing and an empty humidification bottle. The tubing, which should have been replaced every seven days, was not changed as per the physician's orders. Additionally, the nebulizer tubing was not dated or stored properly, as it was left on the bedside table without a bag. Nurse #1 acknowledged the oversight, noting that the tubing should have been changed by the night nurse. Resident #62, admitted with vascular dementia and pulmonary fibrosis, was also found with undated oxygen tubing. The nasal cannula and nebulizer tubing were observed to be dated incorrectly, indicating a failure to adhere to the seven-day replacement schedule. The Unit Manager confirmed that the oxygen tubing should have been labeled with the date it was opened and stored correctly. These deficiencies highlight lapses in following professional standards of practice for respiratory care, as outlined in the facility's policy.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to adhere to its policy regarding the administration of PRN psychotropic medications, specifically Ativan (Lorazepam), for a resident diagnosed with Anxiety, Depression, and Bipolar Disorder. The policy mandates that PRN psychotropic medications should have a 14-day order limit, and if continued beyond this period, a prescriber must document the rationale and anticipated duration. However, the resident was administered PRN Ativan multiple times in November 2024 without a stop date or reevaluation at the 14-day mark. This oversight was confirmed during an interview with a Unit Manager who acknowledged the absence of a stop date or reevaluation as required by the facility's policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Williamstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Adams Commons Nursing & Rehabilitation Cente | 4.3 mi | ★★★★★ | 0 | 0 |
| Bennington Health & Rehab | 11.6 mi | ★★★★★ | 6 | 0 |
| Crescent Manor Care Ctrs | 11.7 mi | ★★★★★ | 10 | 0 |
| Center For Living & Rehabilitation | 11.9 mi | ★★★★★ | 7 | 0 |
| Vermont Veterans' Home | 12.7 mi | ★★★★★ | 6 | 0 |
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