Complete Care at Berkshire LLC

In the surveyor’s words

From the most serious findings on record at Complete Care at Berkshire LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 20, 2026

  Based on facility policy review, clinical record review, review of facility documentation, observation, and staff interviews, it was determined that the facility failed to provide necessary supervision to monitor a resident's whereabouts and prevent an elopement (unauthorized departure from the facility) for one of seven sampled residents at risk for elopement. (Resident 1) This failure resulted in an Immediate Jeopardy situation. The incident has been identified as past non-compliance. Findings include:Review of facility policy entitled, Elopements and Wandering Residents, dated September 1, 2024, revealed staff were to provide adequate supervision to prevent elopements and be vigilant in responding to alarms in a timely manner. […]

• Actual harm, isolatedF600Jun 2, 2022

  Based on clinical record review, review of facility documentation, and resident and staff interviews, it was determined that the facility failed to prevent resident neglect that resulted in a serious injury and actual harm (a fractured left tibia and fibula - lower leg bones) for one resident, who was dependent on staff for assistance with transfers, out of five residents reviewed (Resident R1). Findings include: Clinical record review revealed that Resident R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set assessment (periodic assessment of resident needs) dated March 11, 2022, revealed that the resident required extensive assistance from two staff members to transfer (move to and from bed and chair). […]

• No harm, potential for more than minimal, widespreadF812Nov 20, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF812Jan 13, 2023

  Based on observation it was determined that the facility failed to maintain sanitary conditions in the kitchen. Findings include: Observation during a tour of the kitchen on January 10, 2023, at 10:40 a.m., revealed that the wall near the floor, underneath the three compartment sink was missing with exposed insulation. In the dry storage room there was a brown stain on a ceiling tile near the doorway and on the wall underneath. There was an opened, undated bag of noodles. There were two sanitizing buckets stored on top of an unsealed bag of cake mix and the milk refrigerator contained a tube draining water into a bucket of standing water.

• No harm, potential for more than minimal, widespreadF812Jan 28, 2022

  Based on observation and interview, it was determined the facility failed to serve food under sanitary conditions in the kitchen. Findings include: During observation of the tray line service on January 25, 2022, at 12:00 p.m., the Food Service Director, who was wearing gloves, was observed leaving the tray line area while still wearing gloves and opening the door to the dry storage room to obtain a bag of hamburger buns. He returned to the tray line to continue assembling trays after touching the handle to the dry storage room without changing his gloves. During the same observation, Dietary Aide (DA) 1, also wearing gloves, was observed leaving area by the stove (cook's area), and opening the walk in freezer to obtain frozen patties. […]