Berkshire Rehabilitation & Skilled Care Center

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1) who was severely cognitively impaired, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 01/24/26, several staff members witnessed Certified Nurse Aide (CNA) #1 interact with Resident #1 in a demeaning and derogatory manner, while redirecting him/her.

Inspectors wroteBased on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), the Facility failed to ensure staff implemented and followed their Abuse Policy related to the need to immediately report an allegation of abuse to Facility administration, when: 1). On 01/24/26, Nurse #1 witnessed an incident involving possible verbal and physical abuse between Certified Nurse Aide (CNA) #1 and Resident #1, did not immediately notify Facility administration. but left a note describing the event under the Nursing Supervisor's office door, where it was not discovered until 01/27/26, three days later. 2). On 4/28/26 around 3:45 P.M., although staff were aware that a physical altercation had occurred between Resident #2 and Resident #3, they did not immediately notify a supervisor, per Facility policy, but waited until 8:30 P.M. (almost five hours later) to report it.

Inspectors wroteBased on records reviewed and interviews, for two of three sampled residents (Resident #2 and Resident #3), the Facility failed to ensure that on 04/28/26, after being made aware of an allegation that Resident #3 punched Resident #2 in the nose, they obtained and maintained evidence that a thorough investigation into the allegation had been completed and that a final investigation report was submitted to the Massachusetts Department of Public Health (DPH) within five days, as required.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure a Registered Nurse (RN) worked eight (8) consecutive hours daily, as required. Specifically, the facility failed to ensure that a Registered Nurse worked at least eight consecutive hours daily on four days from 12/28/25 through 1/28/26.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the main facility kitchen used to store, prepare and distribute resident food and beverages was maintained in a clean and sanitary manner in accordance with food service safety standards. Specifically, the facility failed to ensure that:-the fan in the dish room of the main facility kitchen was cleaned and kept free from dust blowing over clean pots and pans.-the dish rack housing clean dish ware and storage rack in the cook's preparation area was kept free of dust and debris to decrease the risk of physical contamination and foodborne illness. -areas in the main kitchen were appropriately cleaned as required and equipment stored per food safety standards.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure two Residents (#15 and #55) out of a total sample of 15 residents, were afforded dignity and privacy relative to use of their medical devices. Specifically, for Residents #15 and #55, the facility failed to ensure dignity for both Residents when privacy covers were not utilized for their urinary drainage bags.

Inspectors wroteBased on record review, and interviews, the facility failed to ensure advanced directives were executed in accordance with the Resident's wishes for two Residents (#2 and #17), out of a total sample of 15 residents. Specifically, the facility failed to ensure the Resident and Resident Representatives wishes were honored in an emergency situation when:1. For Resident #2, the signed Massachusetts Medical Orders for Life Sustaining Treatment (MOLST - medical order form that relays instructions between health professionals about a patient's care based on an individual's right to accept or refuse medical treatment) Form which indicated to attempt resuscitation (Full Code) did not match the Physician orders which indicated Do Not Resuscitate (DNR)/ Do Not Intubate (DNI). 2. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to ensure Notices of Transfer or Discharge and Bed Hold were provided to residents or their resident representatives at the time of transfer or shortly thereafter and that the Office of the State Long-term Care Ombudsman was notified at the time of transfer or shortly thereafter for four Residents (#1, #10, #17, and #57), of five applicable Residents reviewed for hospitalizations, out of a total sample of 15 active records and one closed record. Specifically, the facility failed to ensure Resident's #1, #10, #17, and #57 and/or their Representative were provided a copy of the facility Bed Hold policy, a Notice of Intent to Transfer upon transfers to the hospital or shortly thereafter. [...]

Inspectors wroteBased on record review, and interviews, the facility failed to notify the State Mental Health Authority for a resident review (person-centered assessment taking into account all relevant information) after a significant change in mental condition occurred for one Resident (#1) out of a total sample of 15 residents. Specifically, the facility failed to complete and request a Preadmission Screening and Resident Review Level II screen (PASRR- an evaluation done to determine if a resident has an intellectual or developmental disability and/or serious mental illness and if a Resident is in need of additional specialized support services at the facility) after Resident #1 received emergency mental health support due to mental illness on two occasions.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the person-centered plan of care was revised for two Resident's (#1 and #6), out of a total sample of 15 residents. Specifically, the facility failed to ensure:For Resident #1, care plans were updated when he/she voiced suicidal ideations resulting in the Resident being sent out for a psychiatric evaluation to be conducted at the hospital on two occasions. For Resident #6, nutrition interventions recommended by the Dietitian were reviewed with the Resident's Provider timely and interventions implemented to assist with healing of the Resident's wounds, placing him/her at risk for potential delay in wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist one Resident (#42), out of a total sample of 15 residents, in obtaining routine dental services. Specifically, the facility failed to schedule dental appointments to ensure that Resident #42 received routine dental services as ordered.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure infection control standards were implemented for two Residents (#6 and #55), out of a total sample of 15 residents. Specifically, For Resident #6, the facility failed to minimize the potential spread for infection during a wound dressing change when the Nurse did not change gloves and perform hand hygiene as required increasing the potential for contamination and wound infection. For Resident #55, the facility failed to ensure the urinary drainage bag was maintained off the floor, and that facility staff donned the required personal protective equipment (PPE) when handling the urinary drainage bag.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had moderate cognitive impairment, the Facility failed to ensure he/she was free from abuse from a staff member, when on 08/09/25, while Nurse #1 was assisting Resident #1, he/she grabbed and squeezed Nurse #1's hand, and in response she struck Resident #1 on the back and pulled his/her hair in attempt to release his/her grip. Nurse #1 admitted to engaging in a physical altercation with Resident #1 and the incident was witnessed by another staff member, and an alert and oriented resident. A cognitively intact person would likely experience pain, anger and emotional distress if struck and had their hair pulled by a caregiver.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was newly admitted , was unfamiliar with the facility, the staff, and was having difficulty adjusting to his/her admission, the Facility failed to ensure he/she was free from abuse, when on 05/01/25 at approximately 1:30 P.M., Director of Nurses (DON) #1 engaged in a verbally and physically abusive altercation with Resident #1. DON #1 with the assistance of Certified Nurse Aide #1, physically restrained Resident #1 to retrieve a bottle of medication he/she had in his/her possession, they pinned him/her up against the wall, blocked him/her from exiting the area, held him/her by his/her arms, pried open his/her hand to check for pills and searched his/her pockets, which only served to escalate Resident #1's resistive and combative behaviors.

Inspectors wroteBased on interviews and records reviewed, for one of three sampled residents (Resident #1), and for two of three sampled employees (Certified Nurse Aide #1 and the Substance Use Disorder [SUD] Counselor), the Facility failed to ensure staff implemented and followed their abuse policy related to reporting of abuse allegations and employment requirements. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that on 05/05/25, after Facility Administration was made aware of an allegation of physical abuse of a resident (Resident #1) by Director of Nurses (DON) #1 and Certified Nurse Aide (CNA) #1, that they reported the allegation to the Department of Public Health (DPH) within two hours as required, when it was not reported to DPH until 05/11/25, (six days later).

Inspectors wroteBased on record review and interview, the facility failed to review and revise the plan of care pertaining to urinary catheter care and services for one Resident (#30) out of a total sample of 16 residents. Specifically, the facility failed to review and revise the plan of care when Resident #30's indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body) was changed in the hospital from a suprapubic catheter (an indwelling urinary catheter placed directly into the bladder through the abdomen) to an indwelling urinary catheter (a tube inserted through the urinary tract into the bladder, connected to a drainage bag).

Inspectors wroteBased on record review, and interview, the facility failed to provide care in accordance with professional standards of practice related to Hospice (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease) care for one Resident (#24) out of a total sample of 16 residents. Specifically, for Resident #24, the facility failed to ensure that the Physician orders which indicated agreement with the Hospice recommendations for scheduled pain and anxiety management were implemented and the care plan followed for appropriate pain management and symptom control resulting in the Resident requiring frequent pain and anxiety medication administration for pain and symptom management.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to provide respiratory care and services based on professional standards of practice, for one Resident (#22) out of a total sample of 16 residents. Specifically, for Resident #22, the facility failed to: 1. Change the oxygen tubing as ordered by the Physician. 2. Follow infection control measures related to the care, handling, and/or storage, by ensuring the Resident's oxygen tubing was maintained off the floor and stored in a clean storage bag.

Inspectors wroteBased on interview, and record review, the facility failed to develop a comprehensive Trauma Informed Care Plan for one Resident (#18) out of a total sample of 16 residents. Specifically, for Resident #18, the facility failed to ensure that a comprehensive Trauma Informed Care Plan was developed relative to the Resident's history of Post Traumatic Stress Disorder (PTSD- a mental and behavioral disorder that develops from having experienced a traumatic event, causing flashbacks, nightmares, and severe anxiety).

Inspectors wroteBased on interview, record and policy review, the facility failed to ensure that the required transfer documentation was completed, and that the transfer documentation communicated the appropriate information to the receiving health care institution for one Resident (#40), out of a total sample of 16 residents. Specifically, the facility failed to ensure that Resident #40 was transferred to the emergency room with a form/packet that included important information relative to the Resident's medical history and the reason for transfer, putting the Resident at risk for complications and adverse events upon transfer to the hospital.

Inspectors wroteBased on observations, interview, and policy review, the facility failed to maintain professional standards for safe and sanitary food storage and management in the main kitchen and one out of one kitchenette.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to follow professional standards of infection control to prevent communication and spread of infectious organisms for two Residents (#17 and #47) out of a total sample of 14 residents, and three Residents (#1, #26 and #55) out of three residents reviewed on transmission based precautions. Specifically, the facility staff failed to: 1. ensure proper infection control practices were followed for the use of a urinary catheter (tubing inserted into the bladder to allow urine to drain) for Resident #17. 2. ensure proper infection control practices were provided for the storage of a nebulizer (a device that delivers medication in the form of a inhaled mist) equipment for Resident #47. 3. [...]

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to maintain complete, accurate, and readily accessible medical records for four Residents (#28, #37, #51, #47 and #17) out of a total sample of 14 residents. Specifically, the facility failed to ensure: 1. for Resident #28, that a Substance Abuse/Issues Disorder Evaluation was accurately completed, and a documented history of ETOH (abbreviation for ethyl alcohol, also known as ethanol and the active ingredient in alcohol) abuse was assessed. 2. for Resident's #37, #51 and #47, that accurate information relative to Advanced Directives were documented and consistent across all active medical records. 3. for Resident #17, that documentation was completed weekly as required for urinary catheter bag (bag that holds urine drained from the bladder) changes.

Inspectors wroteBased on observations and interviews, the facility failed to ensure a safe, clean environment for two Residents (#13 and #20), out of a total sample of 14 residents. Specifically, the facility failed to ensure the wheelchairs for Resident's #13 and #20 were free from dirt and debris build-up, repairs done as needed and maintained in a clean manner.

Inspectors wroteBased on interview and record review the facility failed to ensure the attending Physician or Prescribing Practitioner documented rationale for the continued use of an as needed (PRN) antipsychotic medication for one Resident (#22) out of a total sample of 14 residents. Specifically, the facility staff failed to ensure that the Physician or Prescribing Practitioner directly examined the Resident and documented why a PRN antipsychotic medication was still necessary.

Inspectors wroteBased on observations, interviews and records reviewed, the facility failed to maintain a medication pass error rate of less than five percent (%) when the medication error rate was calculated to be 30% for one Resident (#45), out of five applicable residents, in a total of 30 opportunities. Specifically, the 30% medication error rate resulted from Resident's #45's medications not being administered within the ordered time frame.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure medications were secured appropriately on one of one units. Specifically, the facility staff failed to ensure that an unattended medication storage cart was secured and stored to prevent unintentional access and accidental hazard to the unit residents.