Berkshire Place

Based on interviews, and record review, the facility failed to ensure Influenza and/or Pneumococcal vaccines were administered when consent was obtained to receive the vaccine for two Residents (#2 and #29), of five applicable residents reviewed for immunizations, out of a total sample of 13 residents. Specifically, the facility failed to: For Resident #2, administer the Influenza Vaccine when consent was obtained for the Resident to receive the vaccine in January 2026. For Resident #29, administer the Pneumococcal Vaccine when consent was obtained to receive the vaccine in June 2024. Findings include:1. Resident #2 was admitted to the facility in January 2026 with diagnoses including chronic kidney disease (CKD) Stage 3, and Cerebral Infarction, and was over the age of 65. Review of the facility policy titled Influenza Immunization, reviewed in January 2026, indicated the following: -Residents/patients will be offered immunization against influenza as recommended by the Centers for Disease Control and Prevention (CDC) and under guidance by the Massachusetts Department of Public…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, and record review, the facility failed to ensure that COVID-19 immunization was administered after consent was obtained to administer the vaccine for one Resident (#4), of five applicable residents reviewed for immunizations, out of a total sample of 13 residents. Specifically, for Resident #4, the facility failed to administer the COVID-19 immunization when the Resident was eligible to receive the vaccine and written consent for the vaccine was obtained in October 2025. Findings include: Review of the facility policy titled Resident/Patient COVID-19 Immunization, dated October 2021, included the following: -Residents/patients will be offered immunization against COVID-19 as recommended by the Centers for Disease Control and Prevention (CDC) and under guidance by the Massachusetts Department of Public Health (MA DPH). -The COVID-19 vaccine will be offered unless immunization is medically contraindicated or the resident/patient has already been immunized. -If the COVID-19 immunization requires multiple doses, the resident/patient and/or resident representative,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, and record review, the facility failed to ensure professional standards of care were maintained for diabetic management of one Resident (#23) out of a total sample of 13 residents. Specifically, for Resident #23, the facility failed to ensure that the Medical Doctor (MD) was notified and appropriate assessment conducted when the Resident experienced a period of hyperglycemia (high blood sugar). Findings include: Review of the facility policy titled Diabetes Mellitus (DM- disease in which the body's ability to produce or respond to the hormone insulin [a hormone that helps the body regulate blood sugar] is impaired resulting in variable blood glucose [sugar] levels in the blood), Guidelines For (Nursing Care of Resident With), revised 5/06, indicated the following: -Quickly restore normal cerebral function and prevent hyperglycemia or hypoglycemia. -Recognize, treat or prevent complications commonly associated with diabetes. Resident #23 was admitted to the facility in August 2022, with diagnoses including Type II DM (non-insulin dependent type of diabetes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record and policy review, the facility failed to ensure that an as needed (PRN) psychotropic medication (medication that affect the mind, emotions, and behavior) was limited to 14 days for one Resident (#24), of five applicable residents reviewed, out of a total sample of 13 residents. Specifically, the facility failed to ensure that PRN Ativan (Lorazepam: anti-anxiety medication) was limited to 14 days and if not limited, included a Physician determined duration for continued use of the medication. Findings include: Review of the facility policy titled Psychotropic Medications, dated 8/31/23, indicated the following: -PRN psychotropic medications which are not antipsychotic medications are limited to 14 days. -The Attending Physician/Prescriber may extend the order beyond 14 days if he or she feels it is appropriate. -If the Attending Physician extends the PRN order, the medical record will include documented rationale and determined duration. Resident #24 was admitted to the facility in September 2024, with diagnoses including Anxiety Disorder (mental health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, and record review, the facility failed to obtain Physician orders prior to administering a Pneumococcal Vaccination to one Resident (#23) out of five applicable residents reviewed, out of a total sample of 13 residents. Specifically, for Residents #23 the facility failed to obtain a Physician's order prior to administering the Pneumococcal 20-Valent Conjugate Vaccine (PCV20-type of Pneumococcal Vaccination). Findings include: Review of the facility policy titled Resident/Patient Pneumococcal Immunization, reviewed 7/15/22, indicated the following: -A Licensed Nurse will administer the Pneumococcal Vaccine with a standing order from the Medical Director per manufacturer's guidelines for residents/patients. Resident #23 was admitted to the facility in August 2022. Review of Resident #23's immunization record indicated he/she was administered the PCV20 on 5/24/23, while he/she was a Resident in the facility. Further review of the Resident's medical record indicated no documentation a Physician's order was in place prior to or at the time the PCV20 was administered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and records reviewed for one resident (Resident #27) out of a total sample of 12 residents, the facility failed to complete a significant change of status (SCOS) Minimum Data Set (MDS) Assessment within the required 14 days. Findings include: Resident #27 was admitted to the facility in May 2023. Review of the Resident's Medical Record indicated the Resident signed onto Hospice Services on 7/31/23. On 8/16/23 at 9:13 A.M., the surveyor reviewed the SCOS MDS Assessment with an Assessment Reference Date (ARD) of 8/9/23 and noted that it was marked in progress. On 8/16/23 at 12:28 P.M., the surveyor and the MDS Nurse reviewed the Resident's SCOS MDS Assessment with an ARD date of 8/9/23. The MDS Nurse said the date the Resident signed onto Hospice Services started the count down for when the SCOS MDS Assessment should have been completed, and the SCOS MDS Assessment should have been completed within 14 calendar days after 7/31/23, the date the Resident signed onto Hospice Services, and it was not, as required.

Based on record review and interview for one Resident (#199) out of a total sample of 12 residents, the facility failed to implement the plan of care. Specifically, for Resident #199 the facility staff failed to ensure that lab work ordered by the Physician was obtained, resulting in incomplete diagnostic information available for the Attending Physician to make treatment decisions. Findings include: Resident #199 was admitted to the facility in June 2023. Review of the Physician's History and Physical Exam Form signed and dated by the Physician on 6/23/23, indicated to repeat Lytes (also known as an Electrolyte panel, a blood test that measures levels of the body's Sodium (helps control the amount of fluid in the body and helps nerves and muscles work properly), Chloride (helps control the fluid in the body and helps maintain healthy blood volume and blood pressure), Potassium (helps heart and muscles work properly) and Bicarbonate (helps maintain the body's acid and base balance and plays an important role of moving carbon dioxide through the bloodstream). Review of the Resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interview and records reviewed for one Resident (#27) out of a total sample of 12 residents, the facility failed to provide care and services for the use of Oxygen. Specifically, for Resident #27 the facility failed to ensure that Physician's orders were in place for the accurate amount of Oxygen being utilized by the Resident, and care and services of the oxygen tubing. Findings include: Review of the facility policy titled Oxygen, reviewed 7/15/22, indicated the following: -Obtain specific physician order for oxygen therapy. -Change oxygen tubing weekly. Date and initial on tape when changed and apply to tubing. Resident #27 was admitted to the facility in May 2023 with the following diagnoses: Pneumonia (an infection that affects the lungs) and Respiratory Failure (when the lungs are unable to get adequate oxygen to the blood/ body and get rid of carbon dioxide from the body) condition that makes it difficult to breathe on your own). On 8/15/23 at 4:58 P.M., the surveyor observed Resident #27 resting in bed. He/she was receiving Oxygen via nasal cannula (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews for one Resident (#199) out of a total sample of 12 residents, the facility failed to maintain accurate medical records. Specifically, for Resident #199 the facility failed to: 1. Ensure that staff accurately documented Nursing Progress Notes pertaining to the status of the Resident's Foley catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body). 2. Ensure that staff accurately documented the findings of the Resident's skin condition on a Weekly Skin Assessment and Nursing Progress note. Findings include: Resident #199 was admitted to the facility in June 2023 with a Foley catheter. 1. Review of the June 2023 Physician's orders indicated an order to discontinue the Resident's Foley catheter on 6/30/23. Review of a Nursing Progress Note dated 6/30/23 indicated the following: Resident's Foley catheter was removed early this morning. Review of a Nursing Progress Note dated 7/7/23 indicated the following: Resident's Foley patent (not clogged)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.