Above 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 Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with schizophrenia and other chronic conditions did not have documented PASRR screening before admission, and the record lacked the initial PASRR form. A later PASRR completed by the SWD was incomplete because it did not follow the required steps after identifying serious mental illness or assess the need for a Level II referral.
A resident with fragile skin and DM had a care plan calling for Geri sleeves and protective skin care, but staff repeatedly observed the resident without the sleeves. CNA staff relied on the CNA Accountability Record, which did not list the sleeves, and RN leadership confirmed the intervention was not carried over from the care plan to the CNA record.
A resident with COPD, HF, HTN, and continuous O2 therapy had a CPAP machine observed in the room, but there was no physician order or CCP for its use. Staff confirmed the CPAP was present and being used at times, yet no one had verified an order or documented the device’s settings, frequency, or care in the resident’s plan.
Expired Open Insulin Kept in Medication Cart: An opened vial of insulin lispro was found on a med cart with an open date well beyond the manufacturer’s 28-day limit and was still stored with a resident’s labeled medication supply. The resident had DM and was receiving sliding-scale insulin, while the LPN confirmed the vial should have been discarded after 28 days; the DON and ADON were unsure about the specifics, and the pharmacist stated the insulin loses potency after the 28-day period.
A resident admitted with a Foley catheter had an incomplete and inaccurate admission H&P. The MD started the H&P before seeing the resident and later completed it without documenting the Foley, urinary incontinence/retention, or related urinary diagnoses, even though the hospital discharge summary and physician orders reflected urinary issues and catheter use.
Three residents experienced prolonged constipation without timely physician notification or intervention, despite facility policy and physician orders requiring monitoring and reporting. One resident was hospitalized for bowel impaction. Staff interviews revealed LPNs were not consistently checking or reporting bowel movement patterns, and the DON and Administrator were unaware of the lapses.
A resident with severe cognitive impairment and mobility dependence fell and fractured their leg due to inadequate supervision and failure to update their care plan. Despite recommendations for two-person assistance, the care plan inaccurately required only one staff member, leading to the incident. The lack of communication and documentation among the Interdisciplinary Team contributed to this oversight.
A resident with impaired cognition was found on the floor, and the facility failed to thoroughly investigate the incident. The resident's roommate initially reported the fall, but no statement was obtained from them. An LPN's involvement was inconsistent, as they claimed to be attending to another resident at the time. The facility's policy requires obtaining statements from witnesses, but this was not followed. Interviews with staff revealed a lack of clarity and responsibility in the investigation process.
A resident with a history of a Stage 4 pressure ulcer had an air mattress set incorrectly at 300 pounds, despite weighing 176 pounds. Facility policy required the mattress to be adjusted according to the resident's weight, but staff interviews revealed confusion over who was responsible for monitoring the settings. The Wound Care Nurse initially set the mattress and conducted monthly audits, but there was no documentation of ongoing monitoring, leading to inadequate pressure ulcer care.
Missing and Incomplete PASRR Screening for Resident With Serious Mental Illness
Penalty
Summary
The facility did not ensure that a resident with schizophrenia received a preadmission screening for mental disorders before admission, and the resident’s record did not contain documented evidence that a PASRR was completed prior to the original admission to the facility. The resident had diagnoses including schizophrenia, Parkinson’s disease, and diabetes mellitus, and a later quarterly MDS documented severely impaired cognitive skills for daily decision making, no BIMS, and use of antipsychotic medications. A physician’s order also documented Seroquel for schizoaffective disorder, bipolar type, and major depressive disorder, recurrent, severe with psychiatric symptoms. The facility’s electronic record contained no initial PASRR screen form for the resident’s original admission in 2023. A PASRR screen completed by the Social Work Director on a later readmission was incomplete because it did not follow the required steps after indicating the resident had a serious mental illness and did not assess the need for a Level II referral. The Social Work Director stated the hospital was supposed to provide the PASRR form, that it was not received, and that the later screen had to be redone. The Administrator also stated the facility was unable to find the PASRR screen for the resident’s 2023 admission.
Care Plan Intervention Not Carried Over to CNA Record
Penalty
Summary
Resident #13 did not receive a comprehensive person-centered care plan as documented for skin integrity. The resident was admitted with diagnoses including non-Alzheimer's dementia, diabetes mellitus, and depression, and a quarterly MDS documented a BIMS score of 14, indicating the resident was cognitively intact. The comprehensive care plan identified the resident as at risk for skin breakdown due to fragile skin and diabetes mellitus and included interventions for using Geri sleeves and providing protective/preventative skin care, with a physician's order to monitor skin integrity each shift. During multiple observations, Resident #13 was seen without Geri sleeves on the arms while wearing a short-sleeved shirt or a gown. On one observation the resident was in bed without the sleeves, and on another the resident was again observed without them. CNA #1 stated they used the CNA Accountability Record to determine required care and that the ADL instructions did not list Geri sleeves as an intervention. RN Charge Nurse #3 confirmed the Geri sleeves were not listed on the CNA Accountability Record, and the ADON stated the intervention was on the care plan but not documented on the CNA Accountability Record, so CNA #1 likely did not apply the sleeves. The DON stated care plan interventions should be carried over to the CNA Accountability Record for staff to implement the resident's plan of care.
Missing Order and Care Plan for CPAP Use
Penalty
Summary
Safe and appropriate respiratory care was not provided for one resident who used a CPAP machine. Resident #128, who had diagnoses including COPD, heart failure, and hypertension, had intact cognition, shortness of breath when lying flat, and was receiving continuous oxygen therapy. Although the resident stated they used the CPAP machine at times and the machine was observed on the resident’s nightstand during multiple observations, the resident did not have a physician’s order for CPAP use and did not have a comprehensive care plan with goals and interventions for the device. The facility’s policy required a provider order for non-invasive ventilation devices, including initiation, diagnosis, pressure settings, and oxygen requirements. The resident’s record contained an order for continuous supplemental oxygen via nasal cannula at 2 liters per minute every shift and a respiratory care plan for COPD and chronic respiratory failure, but that plan did not include CPAP use. Staff interviews confirmed the absence of an order: an LPN stated they had seen the CPAP on the resident’s nightstand but did not check for an order, an RN stated the resident did not have a physician’s order for the CPAP and did not know who brought it to the room, and the pulmonologist stated that if the resident was using CPAP at the facility, there should have been an order for the proper setting, frequency of use, and care of the machine. The DON also stated they did not know who brought the CPAP to the resident’s room.
Expired Open Insulin Kept in Medication Cart
Penalty
Summary
The facility did not ensure that drugs and biologicals were labeled and stored in accordance with accepted professional principles when an opened vial of insulin lispro on the East A unit was found with an open date of 01/03/2026 and was still being kept in the medication cart on 02/10/2026. The vial was stored in a box inside a plastic bag labeled with Resident #167’s name, and Licensed Practical Nurse #1 confirmed that the insulin had first been opened on 01/03/2026 and should have been discarded after 28 days. The report also noted that there were no other vials of insulin lispro in the cart for this resident. Resident #167 had diagnoses including diabetes mellitus, cerebrovascular accident, and seizure disorder, and the quarterly MDS documented a BIMS score of 15, indicating the resident was cognitively intact. The resident had a physician’s order for insulin lispro sliding scale coverage before meals and at bedtime as needed. During interviews, the Assistant Director of Nursing Services/Nursing Education stated she thought it was good practice to discard insulin after 28 days and was not aware of anything that happens to the insulin, while the DON stated nurses should know to discard it after 28 days and the pharmacist would know what happens after that time. The pharmacist stated insulin lispro should be discarded after 28 days because it loses potency and may not be as effective in controlling blood sugar levels.
Incomplete and Inaccurate Admission H&P Documentation
Penalty
Summary
The facility did not maintain complete and accurately documented medical records for a resident admitted with a Foley catheter. Primary Physician #2 began the admission History and Physical before the resident arrived at the facility and completed it the next day, but the documentation inaccurately stated the resident was continent, had no Foley catheter, and had no diagnosis related to a urinary tract condition. The resident was admitted with diagnoses including hypothyroidism and hypertension, and the physician order on admission documented a Foley catheter #16 French with a 10 cc balloon related to stress incontinence. Record review also showed the hospital discharge summary listed acute urinary retention in the active problem list and urinary disorder and stress incontinence in the past medical history. A later physician order documented the Foley catheter as related to neurogenic bladder. During interviews, Primary Physician #1 stated the admission H&P did not document the Foley catheter, and Primary Physician #2 stated they may have started the template before seeing the resident and then forgot to update it after examining the resident. The Medical Director stated physicians sometimes begin the H&P before seeing the resident, but the record should have been updated to reflect the Foley catheter after the examination.
Failure to Monitor and Report Bowel Movements Resulting in Harm
Penalty
Summary
The facility failed to provide treatment and care according to physician orders, resident preferences, and professional standards for three out of five residents reviewed. Specifically, multiple residents experienced prolonged periods without bowel movements, ranging from six to eleven consecutive days, without documented evidence that the physician was notified or that staff were aware of the need for interventions. Facility policy required nurses to check bowel movement patterns every shift and notify the physician if a resident had no bowel movement in 48 hours, but this protocol was not followed. One resident, admitted with spinal stenosis, spondylosis, and constipation, had no bowel movements for eight and then nine consecutive days. There was no documentation that the physician was notified as required by the resident's orders. The resident was later hospitalized for bowel impaction, with a CT scan confirming fecal impaction and stercoral proctitis. Interviews with staff revealed that certified nursing aides and LPNs were either unaware of how to check bowel reports in the electronic medical record or did not run the reports as required. The primary care physician confirmed they were not notified of the resident's condition. Two additional residents with diagnoses including hemiplegia, dysarthria, multiple sclerosis, ulcerative colitis, and chronic obstructive pulmonary disease also experienced extended periods without bowel movements. Documentation showed no evidence of physician notification or staff awareness of the issue. Staff interviews further revealed a lack of knowledge or adherence to the bowel management protocol. The DON and Administrator were unaware that the bowel reports were not being run and that the issue had not been discussed in Quality Assurance and Performance Improvement meetings.
Failure to Update Care Plan Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for Resident #71, who required the assistance of two staff members for bed mobility. Despite the Rehabilitation Department's recommendations documented in quarterly screens on 1/4/2024 and 4/4/2024, the resident's comprehensive care plan and nursing care instructions were not updated to reflect the need for two-person assistance. As a result, on 6/24/2024, Certified Nursing Assistant #5 provided care alone, leading to the resident falling out of bed while reaching for a stuffed animal, resulting in a fracture of the right leg. Resident #71, who had severe cognitive impairment and was dependent on staff for bed mobility, was admitted with diagnoses including Dementia, Anxiety Disorder, and Hypertension. The resident's care plan inaccurately documented the need for only one staff member for bed mobility, contrary to the Rehabilitation Department's assessment. Interviews with staff revealed that the care plan was not updated due to a lack of communication and documentation regarding the Interdisciplinary Team's decision to not implement the Rehabilitation Department's recommendations. The incident investigation concluded that all care plan interventions were in place, but the lack of documentation and communication among the Interdisciplinary Team led to the failure to update the care plan. Interviews with various staff members, including the Rehabilitation Director and Physical Therapist #1, highlighted discrepancies in the understanding and implementation of the resident's care needs. The Director of Nursing Services confirmed that the Rehabilitation Department was responsible for updating the care plan, and any decision to deviate from the assessment findings should have been documented.
Failure to Investigate Resident Fall Incident
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident involving a resident with impaired cognition, identified as Resident #360, who was found on the floor. The incident was initially reported by the resident's roommate, but the facility did not obtain a statement from the roommate to determine the root cause of the fall. Additionally, there was an inconsistency in the investigation summary regarding the involvement of a Licensed Practical Nurse (LPN), who was reported to have observed the resident on the floor, but their written statement indicated they were attending to another resident at the time. The facility's policy on Accident/Incident Investigation Management requires obtaining statements from witnesses and others with knowledge of the event. However, the investigation into Resident #360's fall did not include a statement from the roommate, who had since passed away, nor did it address the inconsistency in the LPN's statement. The LPN stated they were in the dining room during the incident and did not receive any report from the roommate or observe the resident on the floor. Interviews with the facility's staff, including the Registered Nurse (RN) and Risk Managers involved, revealed a lack of clarity and responsibility in the investigation process. The RN, who completed the Accident and Incident report, did not obtain statements as it was the Risk Manager's responsibility. The Risk Manager acknowledged the missing statement from the roommate and the inconsistency in the LPN's statement but did not recall obtaining the necessary documentation. The Director of Nursing Services admitted to trusting the Risk Manager and did not see the importance of obtaining a statement from the first person who saw the resident on the floor.
Inadequate Monitoring of Air Mattress Settings for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, the deficiency was identified for a resident with a history of a Stage 4 pressure ulcer in the sacral region, who had a physician's order for an alternating-pressure air mattress. During multiple observations, the air mattress's adjustable weight setting was inaccurately set at 300 pounds, despite the resident's recorded weight being 176 pounds. The facility's policy required that the air mattress be adjusted according to the resident's weight to maintain adequate circulation and prevent skin ulcers. However, interviews with staff revealed a lack of clarity and responsibility regarding who was accountable for monitoring and adjusting the air mattress settings. Certified Nursing Assistants were only responsible for checking if the mattress was deflated, while Licensed Practical Nurses did not check the weight settings, assuming it was the responsibility of the Wound Care Nurse. The Wound Care Nurse stated they set the mattress initially and conducted monthly audits but did not document ongoing monitoring. The Wound Care Nurse Practitioner confirmed that the air mattress should correspond to the resident's weight, and the facility was responsible for its monitoring. Despite the Director of Nursing Services stating that the nurses should have been aware of their responsibility to monitor the air mattress, there was no documentation indicating that any specific discipline was tasked with this duty. This lack of oversight and communication led to the deficiency in providing appropriate pressure ulcer care for the resident.
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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 West Babylon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| East Neck Nursing & Rehabilitation Center | 1.1 mi | ★★★★★ | 10 | 0 |
| Our Lady Of Consolation Nursing And Rehabilitive C | 2.9 mi | ★★★★★ | 3 | 1 |
| Massapequa Center Rehabilitation & Nursing | 4.5 mi | ★★★★★ | 0 | 0 |
| Parkview Care And Rehabilitation Center, Inc | 5.6 mi | ★★★★★ | 0 | 0 |
| Daleview Care Center | 5.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.