Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with chronic pain, polyneuropathy, a sacral pressure ulcer, and polyarthritis did not have ordered Morphine sulfate available for administration. The eMAR showed the scheduled morphine dose was held because the pharmacy had not delivered it, while the resident received PRN oxycodone for severe pain. Staff interviews confirmed the medication was not in the Omnicell, and the resident stated the medicine was not available when admitted and was later received during the night.
The facility failed to properly store and monitor perishable food items, leading to expired and improperly stored food in the kitchen's refrigerators. Additionally, the convection oven was not maintained in a clean state, with visible grease and sticky substances. The staff acknowledged these issues, and the facility lacked a specific policy for cleaning the oven.
A resident with multiple health issues reported almost constant pain, which was not adequately addressed in their care plan. Despite frequent requests for pain medication and high pain levels, the care plan categorized the pain as potential rather than actual. Nursing notes often documented no pain, leading to a discrepancy highlighted by surveyors.
The facility failed to update a resident's care plan regarding a defined parameter mattress and did not ensure another resident's participation in care planning. One resident's care plan was not revised to reflect changes in mattress use, while another resident reported not being invited to care planning meetings or receiving a care plan copy. Documentation discrepancies were noted, and the DON was aware of these issues.
A resident with alcoholic cirrhosis and hepatic encephalopathy did not receive a scheduled dose of Lactulose due to its unavailability in the medication cart and an issue with the Omnicell system. The resident confirmed missing doses previously, and the issue was reported to the charge nurse and administrative team.
The facility exceeded the acceptable medication error rate with two errors affecting two residents. One resident missed a dose of Lactulose due to unavailability, while another received incorrect eye drops, Alaway instead of the ordered Pataday. Both incidents highlight failures in medication administration processes.
A resident with chronic kidney disease and other health issues experienced a delay in receiving a CT scan of the abdomen, ordered by a provider. The facility staff failed to schedule the scan promptly, with the CNA responsible for scheduling unable to secure an appointment despite multiple attempts. The Director of Nursing expected timely diagnostics, but the scan was only scheduled over a month later, indicating a significant delay in service provision.
Facility staff failed to follow proper infection control practices during wound care for two residents. Staff did not perform hand hygiene or change gloves appropriately, and did not wear gowns for a resident on Enhanced Barrier Precautions. These deficiencies were confirmed by facility leadership.
A resident with severe cognitive impairment was transferred to a hospital under an ECO without adequate clinical documentation to support the need for the transfer. The facility failed to document the resident's behaviors or any interventions attempted prior to the transfer, as required by their policy. The previous Director of Discharge Planning, who managed the ECO, was not qualified to act as the facility's social worker.
A resident with severe cognitive impairment exhibited threatening and erratic behavior, leading to an emergency custody order. The facility failed to conduct ordered 30-minute checks, document behaviors, or involve a licensed nurse in assessing the resident's condition. Facility policies on behavior monitoring and change of condition were not followed.
A facility failed to document a resident's behaviors that led to an emergency custody order (ECO). The resident, with severe cognitive impairment, had no recorded assessment or interventions by a licensed nurse on the day of the ECO. Facility policies require documentation of significant changes and behaviors, which were not followed in this case.
The facility failed to ensure daily nurse staffing postings contained required information. The surveyor found that the forms used were incomplete, lacking documentation of hours worked by nursing staff and census data for multiple dates across units. Despite instructions to post and update the document at the beginning of each shift, these were not followed, leading to incomplete postings. This issue was discussed with the facility's administration and clinical leadership.
Medication Not Available for Pain Management
Penalty
Summary
The facility failed to ensure Morphine sulfate was available for administration for one resident. The resident had diagnoses including polyneuropathy, a sacral pressure ulcer, and polyarthritis, and the MDS indicated the resident was cognitively intact with a BIMS score of 15 out of 15. The care plan identified the resident as at risk for complications related to opioid use and included administering medications as ordered. The physician’s orders included Morphine Sulfate Oral Tablet 15 mg, 1 tablet by mouth three times a day for pain, and oxycodone HCl Oral Tablet 10 mg every 4 hours as needed for pain. The eMAR showed the morphine dose scheduled for 2200 was coded as hold/see progress notes, and the oxycodone PRN dose was administered at 2050 with a pain level of 9 out of 10. Progress notes documented that the morphine dose was held because the pharmacy had not yet delivered the night dose, and the order was entered as a hold due to nondelivery from the pharmacy. The resident stated the medication was not available when admitted and was later received during the night. Staff interviews showed differing procedures for unavailable medications, including checking the Omnicell, calling the pharmacy, contacting the physician, and requesting stat delivery. The surveyor found that Morphine sulfate 15 mg tablets were not available in the Omnicell.
Deficiencies in Food Storage and Equipment Cleanliness
Penalty
Summary
The facility staff failed to properly store, monitor, and discard perishable food items in the kitchen's walk-in and reach-in refrigerators. During an inspection, a surveyor observed expired food items, including a large container of cottage cheese and two gallons of milk with visible spoilage, as well as an opened package of sliced ham and a container of dill pickle relish, all past their best-used-by dates. Additionally, two large opened cans of fruit cocktail were improperly stored in their original cans. The staff member accompanying the surveyor acknowledged these issues and removed the items. The facility also failed to maintain cleanliness of the convection oven, which was observed to have a moderate amount of grease and sticky substances on its surfaces. The staff member admitted that the oven had not been cleaned recently, despite a facility document indicating a monthly cleaning schedule. However, the document lacked specific dates or initials to confirm when or by whom the cleaning was performed. Furthermore, there was no facility policy for cleaning the convection oven, as confirmed by the regional director of clinical services.
Failure to Address Resident's Actual Pain in Care Plan
Penalty
Summary
Facility staff failed to implement a person-centered care plan that addressed the actual reported pain of a resident. The resident, who had multiple diagnoses including cerebral infarction, bilateral hemiplegia/hemiparesis, morbid obesity, type 2 diabetes mellitus, and chronic osteomyelitis, reported experiencing almost constant pain that interfered with sleep and daily activities. Despite this, the care plan was not updated to reflect the resident's continuous pain, and the Care Area Assessment incorrectly categorized the pain as potential rather than actual. Interviews with the resident confirmed that the pain was unrelieved and had been reported to nursing staff. The MDS coordinator stated that the care plan should be based on the MDS nurse interview, which indicated the resident's pain. However, the corporate regional director for MDS noted that the care plan would only reflect actual pain if documented in the skilled daily nursing notes. The resident's Medication Administration Record showed frequent requests for pain medication with high pain levels reported, yet the nursing notes often documented no pain. This discrepancy was highlighted during a summary meeting with surveyors, indicating a failure to address the resident's actual pain in the care plan.
Care Plan Review and Resident Participation Deficiencies
Penalty
Summary
The facility staff failed to review and revise the care plan for Resident #63 regarding the use of a defined parameter mattress (DPM). The resident, who was assessed with severe cognitive impairment and dependent on others for personal care, had a care plan intervention for a DPM created in early 2023. However, documentation showed that the DPM was removed in March 2023 and reimplemented in April 2023, yet these changes were not reflected in the comprehensive care plan. The facility's policy requires care plans to be updated as changes occur, but this was not adhered to in Resident #63's case. Additionally, the facility staff did not ensure that Resident #121 was given the opportunity to participate in care planning. The resident reported not being invited to a care plan meeting or receiving a copy of the care plan, despite expecting these based on the facility's procedures. The surveyor found no documentation of a care plan meeting or a 'jump start' meeting in the resident's clinical record. A late entry was made for a care plan meeting, but the resident stated that the documents mentioned were not provided. The DON was aware of this issue as of mid-June 2024.
Medication Unavailability for Resident with Liver Disease
Penalty
Summary
Facility staff failed to ensure that a provider-ordered medication, Lactulose, was available and administered to a resident diagnosed with multiple conditions, including alcoholic cirrhosis of the liver with ascites and hepatic encephalopathy. The resident's clinical record indicated a prescription for Lactulose to be given four times daily, but during a medication pass observation, the medication was not found in the medication cart. Attempts to retrieve the medication from the facility's electronic interim box, Omnicell, were unsuccessful, and the issue was reported to the charge nurse and the resident, who confirmed missing doses in the past. The medication administration record for June showed all doses were documented as administered before the missed 9:00 a.m. dose. The regional director of clinical services was informed of the missed dose, and the administrative team began researching the issue. It was later discovered that the Omnicell system did not recognize the resident's connection to the Lactulose order, preventing the medication from being dispensed. This issue was corrected within the Omnicell system, but no further information was provided before the exit conference.
Medication Error Rate Exceeds 5% Due to Missed and Incorrect Medications
Penalty
Summary
The facility staff failed to maintain a medication error rate of less than 5%, resulting in a rate of 6.67% due to two medication errors involving two residents. For one resident, the staff did not administer the provider-ordered medication Lactulose, which is used for hepatic encephalopathy and cirrhosis. During a medication pass observation, the Lactulose was not available in the medication cart, and attempts to retrieve it from the facility's electronic interim box were unsuccessful. The resident's clinical record indicated a standing order for Lactulose to be administered four times daily, but a dose was missed. In another incident, a different resident was administered the incorrect eye drops. The provider had ordered Pataday eye drops, but the resident received Alaway eye drops instead. Although both medications treat similar symptoms, they contain different active ingredients and are not interchangeable. The error was identified when the surveyor reconciled the administered medications with the provider's orders. The facility's pharmacy provider confirmed that the specific eye drop should be administered as per the provider's order.
Delay in Scheduling CT Scan for Resident
Penalty
Summary
The facility staff failed to provide timely radiology services for a resident who required a CT scan of the abdomen as ordered by a provider. The order for the CT scan was placed on 5/31/24, but the facility did not schedule the scan promptly. The resident, who was cognitively intact with a BIMS score of 14 out of 15, had a medical history that included chronic kidney disease, hypertension, peripheral vascular disease, anemia, and diabetes. Despite the order being active, there was no record of the CT scan being performed, and the facility staff had not successfully scheduled the appointment by the time of the survey. Interviews with facility staff revealed a lack of communication and follow-up regarding the scheduling of the CT scan. The CNA responsible for scheduling the scan had been attempting to contact the hospital radiology department but had not secured an appointment. Documentation of these attempts was insufficient, and there was no fax confirmation of the order being sent to the radiology department. The Director of Nursing expressed that the expectation was for diagnostics to be obtained as quickly as possible, and the CNA should have notified the nursing or administrative staff about the delay. Eventually, the CT scan was scheduled for a date over a month after the initial order, highlighting the delay in providing necessary diagnostic services.
Infection Control Deficiencies in Wound Care
Penalty
Summary
The facility staff failed to adhere to proper infection prevention and control practices during wound care for Resident #75 and an unsampled resident, Resident #82. Specifically, the staff did not perform hand hygiene or change gloves appropriately during wound care procedures. For Resident #75, multiple staff members, including a CNA and two LPNs, were observed not changing gloves or performing hand hygiene between tasks such as repositioning a trash can, supporting the resident, and applying new wound dressings. Additionally, the staff did not wear gowns while providing care to Resident #75, who was on Enhanced Barrier Precautions (EBPs), despite facility policies requiring gown and glove use during high-contact care activities. In another instance, during wound care for Resident #82, an LPN was observed failing to perform hand hygiene between removing a wound dressing, cleaning the wound, and applying a new dressing. This resulted in the application of a clean dressing with gloves that had been contaminated by handling the soiled dressing and cleaning the wound. These observations were confirmed by the facility's Administrator, Regional Director of Clinical Services, and Infection Preventionist, who acknowledged the requirement for hand hygiene when changing gloves.
Failure to Document Justification for Resident Transfer
Penalty
Summary
The facility staff failed to ensure that clinical documentation supported the need for a resident's transfer to a local hospital under an emergency custody order (ECO). The deficiency involved one of the sampled residents, who was assessed as having severe cognitive impairment and required supervision for daily activities. The clinical documentation did not include details of the events leading to the issuance of the ECO, nor did it show that a licensed nurse assessed the resident's behaviors or attempted any interventions prior to the transfer. The facility's policy required that behaviors be assessed and documented by nursing staff, with any unusual or increased behaviors reported and recorded in the medical record. However, there was no documentation of the targeted behaviors, side effects, or interventions by a licensed nurse on the day the ECO was obtained. Additionally, the previous Director of Discharge Planning, who managed the ECO, was not a licensed nurse and lacked the necessary qualifications to function as the facility's social worker.
Failure to Provide Behavioral Health Interventions
Penalty
Summary
The facility staff failed to provide necessary behavioral health care and interventions for a resident who exhibited significant behavioral changes. On 8/2/23, the resident threatened to kill their roommate, prompting staff to separate them and place them in different rooms. A nurse practitioner was informed of the resident's confusion and impaired reasoning, and ordered 30-minute checks until the resident could be seen by a provider. However, there was no evidence that these checks were conducted, and the roommate did not change rooms until the following day. On 8/10/23, the facility staff obtained an emergency custody order (ECO) for the resident due to erratic and aggressive behavior, but failed to document the events leading to this decision. There was no record of a licensed nurse assessing the resident or any interventions attempted before the ECO was issued. The resident's clinical documentation lacked details of the behaviors observed, such as difficulty redirecting, ambulating laps, lunging at others, and making threatening remarks to another resident. The facility's policies required staff to communicate changes in patient status to a licensed nurse and document behaviors and interventions in the medical record. However, these procedures were not followed, as evidenced by the absence of documentation regarding the resident's behaviors and the facility's response. The facility's Medical Director was aware of the ECO but did not document any notes regarding the resident's physical aggression.
Failure to Document Resident Behaviors Leading to ECO
Penalty
Summary
The facility staff failed to maintain complete and accurate clinical documentation for a resident, identified as Resident #219, which led to a deficiency. The resident's clinical records did not include documentation of behaviors that prompted the facility staff to request an emergency custody order (ECO) on August 10, 2023. The Minimum Data Set (MDS) assessment for the resident, completed in July 2023, indicated severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of five out of 15. Despite this, there was no documentation of a licensed nurse assessing the resident's behaviors on the day the ECO was requested, nor any record of interventions attempted prior to obtaining the ECO. The facility's policies and procedures, effective January 29, 2024, require staff to communicate any changes in patient status to a licensed nurse immediately and for the nurse to assess and document any significant changes in condition. Additionally, behaviors are to be assessed, monitored, and documented, with any unusual or increased behaviors reported in the medical record. However, these procedures were not followed in the case of Resident #219, as evidenced by the absence of documentation regarding the resident's behaviors and the lack of recorded interventions before the ECO was initiated. This deficiency was discussed with the facility's administration and clinical leadership during a survey meeting in June 2024.
Incomplete Daily Nurse Staffing Postings
Penalty
Summary
The facility staff failed to ensure that the daily nurse staffing postings contained the required information. The surveyor reviewed the facility's posted nurse staffing data and found that the forms used, titled DAILY NURSE STAFFING SUMMARY, were incomplete. Specifically, the forms for Unit 1 and Unit 2 on certain dates did not document the hours worked by nursing staff. Additionally, the census was not documented for multiple dates across both units. The surveyor noted that the facility's form instructed staff to post the document in a prominent place accessible to patients and visitors and to complete it at the beginning of each shift, updating any changes as needed. However, these instructions were not followed, leading to incomplete postings. This issue was discussed with the facility's Administrator, Director of Nursing, Assistant DON, and Regional Director of Clinical Services during a meeting with the survey team.
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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 Vinton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Star City Rehabilitation And Nursing | 1.8 mi | ★★★★★ | 0 | 0 |
| Springtree Healthcare & Rehab Center | 2.1 mi | ★★★★★ | 4 | 0 |
| Our Lady Of The Valley | 3.1 mi | ★★★★★ | 0 | 0 |
| Old Southwest Health And Rehabilitation | 3.6 mi | ★★★★★ | 0 | 0 |
| Friendship Health And Rehab Center | 4.8 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.