Complete Care At Berkshire LLC

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on two of two floors. (First and Second floor)Findings include:Observations on June 17, 2026, from 9:41 a.m. through 1:10 p.m., revealed the following: Gloves and wipes covered by a brown substance were observed on the floor in the First floor shower room along with various pieces of garbage. A green residue was observed beneath the shower heads. An overflowing hamper of dirty clothes along with several pieces of clothing were observed on the floor in the Second floor shower room. A green residue was observed beneath the shower heads.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on four of four nursing units. (First West, First North, Second West, and Second North) Findings include:Observations on April 25, 2026, from 10:30 a.m. through 12:30 p.m., revealed the following environmental issues:In the First floor Lounge, the wood wall trim by the entrance door was marred. The wall above the television had an area of peeling wallpaper which exposed a black area behind it. The wall next to the window by the television had a substance that appeared as multiple black circular marks. Observations in the hallway of the First [NAME] and First North units revealed the following: The wall between rooms [ROOM NUMBERS] had black marks along the length of it and there were two stained ceiling tiles. There was one ceiling tile with brown stains next to room [ROOM NUMBER]. The wall between rooms [ROOM NUMBERS] had black marks and two areas of dried brown liquid.The wall between room…

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 review of facility documentation, results of a test tray audit, resident interview and staff interview, it was determined that the facility failed to provide food that was palatable and at an appetizing temperature on one of four nursing units. (2nd Floor North)Findings include: Review of Food Committee Minutes from December 2025 through February 2026, revealed that residents had stated that their food was served cold and was not palatable. In a review of Grievances from February 2026, it was reported that the beverages were not palatable. Review of facility documentation entitled, Test Tray Meal Evaluation, revealed that the hot entree, starch, and vegetable should be greater than or equal to 135 degrees Fahrenheit (F), and the milk should be below or equal to 41 degrees F at point of service to the residents. Results of a test tray audit conducted on March 20, 2026, at 1:33 p.m., revealed the fish sticks were served at a temperature of 107 degrees F, the tater tots were served at a temperature of 113 degrees F, the mixed vegetables were served at a temperature of 118…

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 facility policy review, observation, and staff interview, it was determined that the facility failed to store and serve food in a sanitary manner in the dietary department and on one of two nursing units. (1st floor) Findings include:Review of the facility policy entitled, Labeling and Dating Inservice, dated August 25, 2025, revealed that staff were to discard items that were past their use-by date.Observations during the kitchen tour on November 18, 2025, at 10:00 a.m., revealed the following:In the freezer, there were bags of French toast, muffins, and fish patties that were opened and not dated. There was a bag of dinner rolls and a box of blueberries that were not sealed and were opened to air. On the floor inside the freezer, there were two areas of a frozen, brown liquid substance that had shoe marks in both. In the walk-in cooler, there was an opened package of breakfast ham that was labeled use-by November 15, 2025. In the preparation area, the utensil drawer had three utensils that had a dried, sticky substance in the serving piece of each. Inside the microwave…

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 clinical record review and staff interview, it was determined that the facility failed to document the rationale for the continued use of as needed (PRN) anti-anxiety medications for two of 24 sampled residents. (Residents 2 and 3)Findings include:Clinical record review revealed that Resident 2 had diagnoses that included dysphagia (difficulty swallowing), malnutrition, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had no cognitive impairment and had been administered an anti-anxiety medication. On September 16, 2025, a physician ordered for staff to administer an anti-anxiety medication (lorazepam) every 12 hours as needed for anxiety. Review of the Medication Administration Record (MAR) revealed that the anti-anxiety medication had been administered three times in November 2025. Clinical record review revealed that Resident 3 had diagnoses that included dysphagia, heart failure, and anxiety. Review of the MDS assessment dated [DATE], revealed…

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 clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the current status of one of 25 sampled residents. (Resident 86)Findings include:Clinical record review revealed that Resident 86 was placed on hospice on March 28, 2025. The MDS assessment dated [DATE], incorrectly indicated in Section O (Special treatments, Procedures, and Programs) that the resident was not on hospice during the previous seven days.In an interview on November 20, 2025, at 9:20 a.m., the Director of Nursing confirmed that Resident 86's MDS assessment was inaccurate.

Based on facility policy review, observation, record review, and staff and resident interview, it was determined that the facility failed to provide services to maintain adequate grooming and hygiene for one of 26 sampled residents. (Resident 25) Findings include: Review of the facility policy entitled, Resident Showers/Bathing, last reviewed November 19, 2024, revealed that staff were to assist residents with hygiene needs following bathing. Clinical record review revealed that Resident 25 had diagnoses that included anxiety and osteoporosis. Review of the care plan revealed that the resident required assistance with activities of daily living (ADLs) and had fragile skin. Staff were to check fingernail length and trim and clean on bath days as needed, and her fingernails were to be kept short. On November 19, 2024, at 12:56 p.m., the resident was observed out of bed in her wheelchair. Her fingernails were long and dirty; there was a dark colored substance underneath the nails. The resident stated that her fingernails needed to be cut. On November 20, 2024, at 10:24 a.m., the…

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 observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on two of two nursing units. (First Floor, Second Floor) Findings include: During the environmental tour of the First Floor nursing unit on December 12, 2023, at various times, the following was observed: The linoleum floor was cracked, broken, and/or taped in resident rooms 125, 126, 127, 128, 132, and 133. The floor was sticky in resident room [ROOM NUMBER]. There was a urine odor in resident rooms [ROOM NUMBERS]. Toilets were soiled with a brown substance in resident rooms [ROOM NUMBERS]. There was a rusty toilet seat in resident room [ROOM NUMBER]. The first floor resident lounge refrigerator was soiled with a brown substance inside. During an environmental tour of the Second Floor nursing unit on December 14, 2023, at various times, the following was observed: The linoleum floor was taped in resident room [ROOM NUMBER]. Light bulbs were not working in resident rooms [ROOM NUMBER]. Toilets…

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 clinical record review and resident interview, it was determined that the facility failed to provide services to enhance each resident's quality of life by offering showers as scheduled to two of 24 sampled residents. (Residents 7, 107) Findings include: Clinical record review revealed that Resident 7 had diagnoses that included hemiplegia and depression. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was oriented and needed substantial/maximal assistance from staff for bathing. The resident was to receive a shower twice per week on Mondays and Thursdays. During an interview on December 12, 2023, at 12:05 p.m., the resident reported that she preferred to take a shower twice a week and was not offered the opportunity to do so. Review of documentation in the clinical record revealed that the resident was not offered a shower seven of nine scheduled times from November 13, 2023, through December 11, 2023. Clinical record review revealed that Resident 107 had diagnoses that…

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 clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was complete to accurately reflect the resident's status for one of 24 sampled residents. (Resident 32) Findings include: Clinical record review revealed that Sections C (Cognitive Patterns) and D (Mood) of Resident 32's MDS assessment dated [DATE], was incomplete. In an interview on December 15, 2023, 12:57 p.m., the Administrator confirmed that the identified MDS sections were not completed during the assessment period to reflect the resident's current status.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and interview it was determined that the facility failed to provide necessary services to maintain good personal hygiene for three of 24 sampled residents. (Residents 44, 91, 116) Findings include: Clinical record review revealed that Resident 44 had diagnoses that included tremor, osteoarthritis left hand, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had no memory impairment and required assistance from staff with daily hygiene and grooming. Review of the current care plan revealed that staff was to provide the resident assistance with hygiene. Observations on December 12, 2023, at 2:16 p.m. and December 14, 2023, at 1:09 p.m., revealed that the resident had long and jagged fingernails with a dark brown substance under the nails. Clinical record review revealed that Resident 91 had diagnoses that included generalized muscle weakness and mild cognitive impairment and end stage renal disease.…

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.