Berkshire Nursing & Rehabilitation Center

Inspectors wroteBased on record review and interviews the facility did not ensure each resident received preadmission screening for individuals with a mental disorder. This was identified for one (1) (Resident #9) of 32 residents reviewed for Preadmission Screening and Resident Review (PASRR). Specifically, Resident #9 with diagnosis of schizophrenia (a chronic, severe brain disorder that distorts how a person thinks, feels, acts, and perceives reality) was originally admitted to the facility on [DATE]; there was no documented evidence that a Preadmission Screening and Resident Review was completed for Resident #9, prior to their admission to the facility. Additionally, the Preadmission Screening and Resident Review screen form completed on 07/18/2025 was incomplete and did not assess the need for a Level II referral. [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey, the facility did not ensure that a comprehensive person-centered care plan was implemented for one (1) (Resident #13) of three (3) residents reviewed for skin integrity. Specifically, Resident #13 was assessed to have fragile skin and required use of the Geri sleeves according to the Comprehensive Care Plan. During multiple observations, Resident #13 was observed without the use of the Geri sleeves. The finding is: A facility policy and procedure titled Comprehensive Care Plan, last reviewed 06/2025, documented the Person-Centered Care Plan is developed to include information necessary to properly care for the residents. The Comprehensive Care Plan will be implemented by qualified members of the facility staff. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility did not ensure that each resident who needs respiratory care is provided care in accordance with the professional standards of practice and the comprehensive person-centered care plan. This was identified for one (1) (Resident #128) of four (4) residents reviewed for Respiratory Care. Specifically, Resident #128 indicated they use the Continuous Positive Airway Pressure machine (CPAP- a machine used for obstructive sleep apnea: a condition with temporary pauses in breathing during sleep) that was observed on their nightstand. Resident #128 did not have a physician's order or a Comprehensive Care Plan (CCP) with goals and interventions for the use of the Continuous Positive Airway Pressure machine. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and include the appropriate instructions and the expiration date to facilitate considerations of precautions and safe administration of medications. This was identified on one (1) (East A unit) of three (3) nursing units. Specifically, on 02/10/2026, a medication cart on the East A nursing unit was observed with a vial of Insulin lispro (fast acting insulin to be administered pre-meal based on a sliding scale to prevent blood sugar from spiking after the meal) with an open date of 01/03/2026. The insulin vial was not discarded after 28 days as per the manufacturer's guidelines. [...]

Inspectors wroteBased on record review and interviews, the facility did not maintain medical records on each resident that are complete and accurately documented. This was identified for one (1) (Resident #174) of three (3) residents reviewed for Urinary Catheter. Specifically, Resident #174 was admitted with a foley catheter. Primary Physician #2 initiated documentation of an admission History and Physical evaluation on 02/09/2026, prior to the resident's arrival to the facility and did not complete the documentation until 02/10/2026. The evaluation inaccurately documented Resident #174 was continent, had no foley catheter, and had no diagnosis related to urinary tract. The finding is: The facility's policy titled, Physician Visits, last reviewed 1/2026, documented the Medical Staff shall provide for a medical history and physical examination to be done within 48 hours after admission to the facility. [...]

Inspectors wroteBased on observation, record review, and staff interviews during an abbreviated survey (NY002604352) initiated on 09/03/2025, the facility failed to ensure residents received treatment and care according to professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for three (3) of (5) residents reviewed. Specifically, 1) Resident #1 had no bowel movements eight (8) consecutive days from (07/19/2025 through 07/26/2025 and again for nine (9) consecutive days from 07/28/2025 through 08/05/2025. 2) Resident #2 had no bowel movements for eight (8) consecutive days from (08/15/2025 through 08/22/2025 and again for (8) consecutive days from 08/24/2025 through 08/31/2025. 3) Resident #3 had no bowel movements for eight (8) consecutive days from 06/06/2025 through 06/13/2025 and again for 11consecutive days from 06/15/2025 through 06/25/2025. [...]

Inspectors wroteBased on observations, interviews and record reviews during the Abbreviated Survey (complaint #NY00347913) completed on 10/30/2024, the facility did not ensure that all alleged violations of resident abuse, neglect, exploitation, or mistreatment were reported to the New York State Department of Health, or the local law enforcement as required. This was evident for 1 of 3 residents reviewed for abuse (Resident #1). Specifically, an allegation was reported to the facility by Staff Member #1 that they witnessed Certified Nursing Assistant #1 hitting Resident #1 with their elbow. The facility did not report the allegation within two hours to the New York State Department of Health or the local law enforcement as required.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 8/14/2024 and completed on 8/20/2024, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. This was identified for one (Resident #71) of eight residents reviewed for Accidents. Specifically, Resident #71 required the assistance of two staff members for bed mobility as per the Rehabilitation Department screening on 1/4/2024 and 4/4/2024. The resident's comprehensive care plan and nursing care instructions for the Certified Nursing Assistants were not updated to reflect the Rehabilitation Department's recommendations. During the morning care on 6/24/2024, Certified Nursing Assistant #5 turned the resident on their side to clean the resident's back and the resident fell out of the bed. [...]

Inspectors wroteBased on record review and interviews conducted during a Recertification Survey and Abbreviated Survey (Complaint #NY 00322088) initiated on [DATE] and completed on [DATE], the facility did not have evidence that all alleged violations were thoroughly investigated in response to allegations of abuse, neglect, and mistreatment. This was identified for one (Resident #360) of eight residents reviewed for Accident. Specifically, Resident #360 with impaired cognition was found on the floor on [DATE]. The incident was reported to the facility staff by the resident's roommate. The facility did not obtain a statement from the resident's roommate to identify the root cause of the incident. Additionally, the Accident and Incident investigation summary indicated Licensed Practical Nurse #5 observed the resident on the floor; [...]

Inspectors wroteBased on observations, record review, and staff interviews during the Recertification Survey initiated on 8/14/2024 and completed on 8/20/2024, the facility did not ensure that each resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for one (Resident # 95) of two residents reviewed for Pressure Ulcers. Specifically, Resident #95 had a history of a Pressure Ulcer of the Sacral (the portion of the spine between the lower back and tailbone) Region. Resident #95 had a physician's order for an alternating-pressure air mattress. During multiple observations, the adjustable weight setting for the air mattress, which is meant to correspond to the resident's weight, was not set accurately. The finding is: [...]