SWEET BROOK OF WILLIAMSTOWN REHABILITATION & N CTR

Nursing Home Inspector

1561 COLD SPRING ROAD
WILLIAMSTOWN, MA 01267
Berkshire County
Phone: 413-458-8127
Provider Number: 225189
Last Inspection: 02/01/2017

About the Nursing Home

Number of Beds: 184
Number of Residents: 110
Beds Available: 74
Percent Occupancy: 60%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

37

Facility 		14

County 		16

MA 		20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 
37

2017		 29

2015		 23

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

2/1/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Pattern : Minimal 4 3/15/2017
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 3/15/2017
 
Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Pattern : Minimal 4 3/15/2017
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Pattern : Minimal 4 3/15/2017
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 3/15/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 3/15/2017
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3 3/15/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Isolated : Minimal 3 3/15/2017
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 3/15/2017
 
Failed To: 1) Receive registry verification that a nurse aide has met the required training and skills that the State requires; and 2) ensure nurse aides receive the required retraining after 24 months if nursing related services were not provided for monetary compe Isolated : Minimal 3 3/15/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 3/15/2017
 

10/19/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Try to resolve each resident's complaints quickly. Isolated : Minimal 3 11/13/2015
 
Failed To: Reasonably accommodate the needs and preferences of each resident. Isolated : Minimal 3 11/13/2015
 
Failed To: Assess in a timely manner the resident when the resident enters the nursing home. Isolated : Minimal 3 11/13/2015
 
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Isolated : Minimal 3 11/13/2015
 
Failed To: Assure that each resident’s assessment is updated at least once every 3 months. Isolated : Minimal 3 11/13/2015
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 11/13/2015
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 11/13/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 11/13/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 11/13/2015
 

8/21/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 10/24/2014
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 10/24/2014
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 10/24/2014
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 10/24/2014
 
Failed To: Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. Widespread : Potential 4 10/24/2014
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 10/24/2014
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 10/24/2014
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

4/11/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from all abuse, physical punishment, and involuntary separation from others. Isolated : Actual 4 5/24/2017
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 5/18/2017
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 5/18/2017
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 5/18/2017
 

11/22/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 1/5/2017
 

1/12/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Actual 4 2/15/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Actual 4 2/15/2016
 

4/1/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care for each resident in a way that maintains or improves their quality of life. Isolated : Minimal 3 4/23/2015
 

3/25/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Actual 4 3/25/2015
 
Failed To: Ensure that residents are safe from serious medication errors. Isolated : Actual 4 3/25/2015
 

2/3/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 3/6/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MA State Avg
Number of Residents 110 94.47 96.79
Registered Nurses 0.51 0.77 0.89
Licensed Practical / Vocational Nurses 0.67 0.84 0.84
Certified Nursing Assistants 2.05 2.12 2.30
Total Staff Hours 3.23 3.72 4.03

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MA State Avg%
of high risk long-stay residents with pressure ulcers 5 4 4
of long-stay residents assessed and appropriately given the pneumococcal vaccine 92 94 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 59 95 95
of long-stay residents experiencing one or more falls with major injury 2 3 3
of long-stay residents who have depressive symptoms 8 3 2
of long-stay residents who lose too much weight 3 4 5
of long-stay residents who received an antianxiety or hypnotic medication 23 28 20
of long-stay residents who received an antipsychotic medication 27 20 18
of long-stay residents who self-report moderate to severe pain 5 2 4
of long-stay residents who were physically restrained 0 1 0
of long-stay residents whose ability to move independently worsened 16 18 18
of long-stay residents whose need for help with daily activities has increased 11 14 14
of long-stay residents with a catheter inserted and left in their bladder 1 0 1
of long-stay residents with a urinary tract infection 2 1 3
of low risk long-stay residents who lose control of their bowels or bladder 35 43 54
of short-stay residents assessed and appropriately given the pneumococcal vaccine 71 82 79
of short-stay residents who had an outpatient emergency department visit 17 11 11
of short-stay residents who made improvements in function 76 74 60
of short-stay residents who newly received an antipsychotic medication 1 0 1
of short-stay residents who self-report moderate to severe pain 23 7 14
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 61 86 82
of short-stay residents who were rehospitalized after a nursing home admission 18 17 22
of short-stay residents who were successfully discharged to the community 43 58 56
of short-stay residents with pressure ulcers that are new or worsened 0 0 0