Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Berkshire Rehabilitation & Skilled Care Center during CMS and state inspections, most recent first.
A nurse physically abused a cognitively impaired resident by striking the resident's back, pulling their hair, and pinching their arm after the resident grabbed and squeezed the nurse's hand during an episode of restlessness. The incident, witnessed by another nurse and a resident, occurred despite facility policies prohibiting such actions, and the nurse admitted to reacting physically out of pain and uncertainty.
A resident with a history of substance use and mental health disorders, who was newly admitted and agitated, was physically restrained and verbally confronted by the DON and a CNA during an attempt to retrieve a bottle of pain medication from the resident's possession. The staff pinned the resident against a wall, blocked movement, pried open the resident's hand, and searched pockets, escalating the situation and violating abuse prevention policies.
Staff did not immediately report a witnessed physical altercation involving a resident and two staff members, as required by facility policy. The incident involved physically restraining and searching a resident with a history of substance use and mental health disorders. Additionally, required background checks were not completed prior to employment for a CNA and a SUD Counselor.
A resident with a history of substance use and mental health disorders was physically restrained and searched by the DON and a CNA after being found with prescription medication. The incident was reported to facility administration, but the required report to the Department of Public Health was delayed by six days due to a misunderstanding of reporting timelines, resulting in a deficiency for failure to report suspected abuse within the mandated timeframe.
A resident's care plan was not updated after a hospital visit resulted in a change from a suprapubic catheter to an indwelling urethral Foley catheter. The facility also failed to document the catheter size in the Physician's orders, as acknowledged by the DON.
A resident with vascular dementia receiving hospice care did not have physician-approved hospice recommendations for scheduled Morphine and Lorazepam implemented, leading to frequent PRN medication use for pain and anxiety. Facility staff failed to enter these orders into the electronic medical record, and a hospice care plan was not created.
A facility failed to provide appropriate respiratory care for a resident by not changing oxygen tubing as ordered and not following infection control measures. The resident, with a history of shortness of breath and emphysema, had oxygen tubing dated incorrectly, indicating it was not changed weekly as required. Additionally, the tubing was found on the floor instead of stored in a clean bag, violating facility policy.
A facility failed to develop a comprehensive Trauma Informed Care Plan for a resident with PTSD. The facility's policy requires such a plan to be documented by Social Services with the IDT, but no evidence of this was found in the resident's medical record. A social worker confirmed that a care plan should be created for residents with PTSD, yet the review showed no reference to the resident's PTSD, triggers, or interventions.
A facility failed to provide necessary transfer documentation for a resident with schizophrenia and Parkinson's disease, who was transferred to the hospital for mental health evaluation. The required transfer packet, which should have included medical history and medication information, was not completed or sent, as confirmed by staff interviews.
Nurse Engages in Physical Abuse of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a nurse engaged in physical abuse of a resident with moderate cognitive impairment. The incident took place as the nurse was assisting the resident, who had recently returned from the hospital with fractured ribs and was known to be restless and at risk for falls. The resident, who had diagnoses including vascular dementia, psychotic disorder with delusions, and generalized anxiety disorder, attempted to stand from his wheelchair and, during the interaction, grabbed and squeezed the nurse's hand, causing her pain. In response, the nurse struck the resident on the back, pulled the resident's hair, and pinched the resident's arm in an attempt to make the resident release her grip. These actions were witnessed by another nurse and an alert resident. The facility's policy on abuse, neglect, and exploitation, implemented in February 2023, explicitly prohibits physical abuse, including hitting, slapping, and pulling hair. Despite this policy, the nurse admitted to engaging in a physical altercation with the resident, stating that she reacted out of pain and uncertainty about how to de-escalate the situation. The incident was reported through the Health Care Facility Reporting System, and witness statements confirmed the physical actions taken by the nurse, as well as the use of profanity and inappropriate comments in the presence of residents immediately following the event. The investigation found that the resident, who was moderately cognitively impaired, would likely have experienced pain, anger, and emotional distress as a result of being struck and having their hair pulled by a caregiver. The incident was substantiated as physical abuse by the facility's internal investigation, based on direct observations, staff and resident interviews, and review of the facility's abuse prevention policy.
Resident Subjected to Physical and Verbal Abuse During Medication Retrieval
Penalty
Summary
A newly admitted resident, who was unfamiliar with the facility and staff and had difficulty adjusting to the admission, was subjected to both verbal and physical abuse by the Director of Nurses (DON) and a Certified Nurse Aide (CNA). The incident occurred when the resident, who had arrived with a bag of medications and was agitated due to the unexpected nature of the admission, was observed taking pain medication from a bottle in his possession. When approached by staff, the resident refused to relinquish the medication, leading to an escalation of the situation. The DON, with the assistance of the CNA, physically restrained the resident by pinning him against the wall, blocking his exit, holding his arms, prying open his hand, and searching his pockets. Multiple staff interviews confirmed that the resident was held against the wall in an alcove across from the nurses' station, was visibly upset, and repeatedly resisted the staff's actions. The altercation was described as loud and chaotic, with both the DON and the resident yelling, and lasted several minutes. The actions taken by the DON and CNA were in direct violation of the facility's abuse prevention policy, which prohibits unreasonable confinement and abuse of any kind. The resident involved had a medical history that included alcohol dependence with alcohol-induced persisting amnesic disorder, opioid abuse, major depressive disorder, and post-traumatic stress disorder. At the time of the incident, the resident was alert, oriented, and able to make his needs known, though his Health Care Proxy was activated prior to admission. The report notes that, based on the reasonable person concept, the resident would likely have experienced psychosocial harm, fear, anxiety, or anger as a result of being restrained and searched by staff entrusted with his care.
Failure to Report Abuse Allegation and Complete Pre-Employment Screening
Penalty
Summary
Staff failed to implement and follow the facility's abuse policy regarding the immediate reporting of abuse allegations and employment screening requirements. On one occasion, several employees witnessed the DON and a CNA physically restrain a resident against a wall, search the resident's pockets, and pry open the resident's hand in an attempt to retrieve medication. Despite multiple staff witnessing this physical altercation, none reported the incident immediately to the Administrator or DON, and the event was not brought to their attention until four days later. The SUD Counselor, who witnessed the end of the altercation, acknowledged not reporting the incident until several days after it occurred, contrary to facility policy requiring immediate reporting of abuse allegations. The resident involved had a history of alcohol dependence with alcohol-induced persisting amnesic disorder, opioid abuse, major depressive disorder, and PTSD. The resident was alert, oriented, and able to make needs known, with an activated health care proxy prior to admission. During the incident, the resident was agitated, uncooperative, and resisted being held, repeatedly telling staff to leave them alone. The altercation ended after staff removed a lighter from the resident's pocket, and the resident was subsequently sent to the emergency department for evaluation due to combativeness and uncertainty about medication ingestion. Additionally, the facility failed to conduct required background checks prior to employment for two staff members. The CNA involved in the incident began working at the facility over two months before a CORI check was completed, and there was no documentation of a Massachusetts Nurse Aide Registry check for the SUD Counselor prior to employment. The Administrator confirmed that these checks should have been completed before the staff began working, as required by facility policy.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
On 05/05/25, facility administration was made aware of an allegation of physical abuse involving a resident and two staff members, the Director of Nurses (DON) and a Certified Nurse Aide (CNA). The incident, which occurred on 05/01/25, involved the DON and CNA physically restraining the resident, searching their pockets, and removing personal items after the resident was found with a bottle of prescription medication. The resident, who had a history of alcohol dependence, opioid abuse, major depressive disorder, and post-traumatic stress disorder, was described as alert and oriented, with an activated Health Care Proxy prior to admission. The incident was reported to the administrator both verbally and in writing by the Substance Use Disorder (SUD) Counselor on 05/05/25. Despite facility policy requiring that all allegations of abuse be reported to the state agency within two hours, the allegation was not reported to the Department of Public Health (DPH) until 05/11/25, six days after the administration was notified. The delay occurred because the current DON misunderstood the reporting requirements, believing she had five days to submit the allegation. The failure to report the suspected abuse within the required timeframe constituted a deficiency in the facility's compliance with abuse reporting regulations.
Failure to Update Care Plan for Catheter Change
Penalty
Summary
The facility failed to review and revise the care plan for a resident who had a change in urinary catheter type. The resident, admitted with a diagnosis of Neuromuscular Dysfunction of the Bladder, initially had a care plan for a suprapubic catheter. However, after a hospital visit, the suprapubic catheter was replaced with an indwelling urethral Foley catheter. Despite this significant change, the care plan was not updated to reflect the new catheter type. Additionally, the October 2024 Physician's orders for the resident included instructions for Foley catheter care but did not specify the size of the Foley catheter or the retention balloon. During an interview, the Director of Nursing acknowledged that the care plans should have been updated when the catheter type was changed, and the catheter size should have been documented in the Physician's orders.
Failure to Implement Hospice Care Recommendations
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for a resident receiving hospice care. The resident, who was admitted with vascular dementia and severe cognitive impairment, was dependent on staff for all activities of daily living and was receiving hospice care services. Despite hospice recommendations for scheduled pain and anxiety management, the facility did not implement the physician-approved orders for scheduled administration of Morphine and Lorazepam, which were intended to manage the resident's pain and anxiety effectively. The hospice care narrative notes recommended scheduling Morphine 0.25 ml and Lorazepam 0.5 mg twice daily, in addition to existing PRN orders. However, the facility's records showed no evidence that these recommendations were reviewed, accepted, or declined, nor were they implemented in the resident's care plan. The medication administration records indicated that the resident frequently required PRN doses of Morphine and Lorazepam for pain and anxiety, suggesting inadequate management of these symptoms due to the lack of scheduled medication administration. Interviews with facility staff revealed a breakdown in communication and process. The MDS Nurse acknowledged the absence of a hospice care plan in the resident's medical record and admitted that it should have been created following the significant change assessment. The Staff Development Coordinator confirmed that the hospice recommendations had been approved by the provider but were not entered into the electronic medical record. The Director of Nursing recognized the oversight and noted that the hospice nurse, who visited weekly, should have identified the failure to implement the recommendations.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not changing the oxygen tubing as ordered by the physician and not following infection control measures. The resident, who was admitted with diagnoses including shortness of breath, dependence on supplemental oxygen, and emphysema, had a physician's order for oxygen via nasal cannula at two liters per minute and to change the oxygen tubing every Sunday during the 11-7 shift. However, the tubing was observed to be dated 9/23/24, indicating it had not been changed as per the order, despite being signed off in the treatment administration record as changed on 9/29/24. Additionally, the facility did not adhere to infection control protocols regarding the handling and storage of the oxygen tubing. The surveyor observed the oxygen tubing and nasal cannula on the floor under the resident's bed and wheelchair, rather than stored in a clean plastic bag as required by the facility's policy. Nurse #1 confirmed that the tubing should not be on the floor and acknowledged the absence of a plastic storage bag in the resident's room, as well as the discrepancy in the tubing change date.
Failure to Develop Trauma Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive Trauma Informed Care Plan for a resident with a history of Post Traumatic Stress Disorder (PTSD). The facility's policy requires that a trauma informed care plan be documented in the resident's medical record by Social Services in conjunction with the Interdisciplinary Team (IDT). However, upon review of the resident's medical record, there was no documented evidence of a comprehensive care plan addressing the resident's PTSD. During an interview, a social worker acknowledged that an initial baseline care plan should be completed upon admission and that a diagnosis of PTSD should be noted on the mood care plan. The social worker further stated that if a resident had active symptoms of PTSD, a specific care plan should be created. Despite this, the review of the resident's care plans revealed no reference to the history of PTSD, possible triggers, or any individualized interventions.
Failure to Provide Required Transfer Documentation
Penalty
Summary
The facility failed to ensure that the required transfer documentation was completed and communicated appropriately when transferring a resident to the emergency room. Specifically, the facility did not provide a transfer packet containing essential information such as contact details, physician orders, nursing assessments, medication lists, and other relevant medical information for a resident who was transferred under a Section 12 order for mental health evaluation. This omission put the resident at risk for complications and adverse events upon transfer to the hospital. The resident involved had diagnoses of schizophrenia and Parkinson's disease and was found in a state that necessitated transfer to the hospital. Despite the facility's policy requiring a comprehensive transfer packet, there was no documented evidence that such a packet was completed or sent with the resident. Interviews with facility staff, including a nurse and the Assistant Director of Nursing, confirmed that the transfer packet was not located, and they could not verify that the necessary information was provided to the receiving facility.
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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 Sandisfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Geer Nursing And Rehabilitation | 12.5 mi | — | 0 | 0 |
| Timberlyn Heights Nursing And Rehabilitation | 13.1 mi | — | 1 | 0 |
| Fairview Commons Nursing & Rehabilitation Center | 13.7 mi | — | 0 | 0 |
| Lee Healthcare | 15.7 mi | — | 17 | 0 |
| Noble Horizons | 17.1 mi | — | 30 | 1 |
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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 August 2026) and official state health department websites.