Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Berkshire Place during CMS and state inspections, most recent first.
A resident with intact cognition and psychiatric diagnoses sustained a left eyebrow laceration when another resident with a documented history of escalating aggressive and threatening behaviors struck them with a cane during a hallway dispute. The aggressive resident had multiple prior documented incidents, including verbal threats to kill others, attacking a roommate with a cane over TV volume, throwing objects during activities, and throwing a lunch plate at staff. Despite these events, the care plan was not updated with interventions to address physical aggression toward other residents, and a psychiatric recommendation for PRN trazodone for agitation, anxiety, and insomnia was only implemented as PRN for insomnia. The failure to assess, monitor, and implement effective interventions for the aggressive resident’s behaviors led to the assault and injury and, per the report, placed this and other residents at risk of serious physical and psychosocial harm.
A resident with impulse disorder, mood and anxiety diagnoses, and a history of escalating verbal and physical aggression had multiple documented incidents of threats, object throwing, and assault with a cane. Despite a psychiatric consult recommending PRN trazodone for agitation, anxiety, and insomnia, the provider order listed insomnia only, and the care plan was not updated with specific interventions to address the resident’s physically aggressive behaviors after several documented events. Subsequently, the resident struck another resident with a cane, causing a facial laceration that required wound closure and ongoing treatment.
The facility failed to provide ordered catheter care for three residents with Foley and suprapubic (SP) catheters. One resident with neurogenic bladder had physician orders for monthly Foley changes and evaluation by urology when urine became cloudy and blood-tinged, but records showed no Foley exchange after a prior hospital procedure and no evidence that urology was contacted, despite later emergency room findings of a crusted catheter, meatal erosion, urinary retention, and foul-smelling urine. A second resident with malignancies and an SP catheter had an order for urology follow-up and a documented plan for an SP exchange at four weeks in the facility, yet records showed no SP exchange after the last urology visit, even though nursing staff were reportedly competent to perform SP exchanges. A third resident with flaccid neuropathic bladder and an SP catheter missed a scheduled urology appointment for an SP exchange, and the facility could not show any subsequent urology visits or SP catheter exchanges as ordered.
A resident with dementia, hemiplegia, and hemiparesis experienced a progressive decline in mobility, going from ambulating up to 150 ft to being non-ambulatory and dependent for bed mobility and transfers. Staff and the DON acknowledged severe bilateral LE contractures, and surveyors observed the resident in bed with contractures, including one instance where the heel was pressed against the buttock. Although an RNP ordered PT for emerging contractures, PT was not completed until much later, and the record did not show timely therapy or other interventions to address the decline.
Failure to address severe weight loss and nutrition needs for a resident with dementia and a stage 4 pressure ulcer. The resident lost 11.4% of body weight over a short period, but the record did not show a timely reweigh, RD assessment, or new interventions for the weight loss. The record also did not show a timely RD nutrition consult related to the pressure injury, despite wound documentation calling for nutrition optimization.
Food storage and hand hygiene deficiencies were identified in the main kitchen and multiple kitchenette areas. Spoiled fruit, an unlabeled open bag of sausage patties, and several opened cereal bags were found without discard dates, and a plate of prepared food was stored in an upper cabinet. In the kitchen, a Dietary Aide scraped dirty dishes with bare hands and rinsed her hands in the sanitizer sink instead of the handwashing sink.
The facility failed to maintain documentation and evidence of its QAPI activities for a PIP involving significant weight loss. Review of the QAPI binder showed the PIP was in place, but there was no documentation of plan implementation, evaluation of corrective actions, or monitoring and auditing of related data. The Administrator and DON were unable to provide the requested evidence during interview.
Failure to follow a physician order for Metoprolol Succinate ER occurred when a resident with HTN and HF had an order to hold the medication if SBP was below 100 and/or HR was below 60, but the MARs did not show that HR was obtained before administration. An RN acknowledged there was no documentation of HR checks, and the DON stated she would expect the order to be followed and the resident's HR to be obtained before the medication was given.
Failure to Provide Pressure Ulcer Care and Offloading: A resident with a stage 4 pressure ulcer had delayed RD involvement despite repeated wound provider recommendations, and wound-related nutrition orders were not implemented until much later. Another resident with severe cognitive impairment, immobility, and prior heel pressure injuries was repeatedly observed without ordered heel booties or pillows for offloading, and staff acknowledged the care plan was not being followed.
A resident readmitted with sepsis had an active order for weekly CBC and CMP testing, but the labs were not obtained on multiple scheduled opportunities. An RN stated the order was entered incorrectly in the EMR so it did not alert staff to complete the lab slip, and the DON acknowledged the ordered lab work was not obtained as ordered.
Insufficiently trained dietary staff failed to properly test the dish machine sanitizing temperatures. The AFSD measured water from a cup collected during the cycle and used the machine’s external gauge, but did not know to use temperature test strips in the manifold or the proper method for applying the self-adhesive strip. Other dietary staff said they did not know how to perform the testing, while a Dietary Cook stated DAs were responsible for it.
A resident with dementia and anxiety disorder, who was cognitively intact, threatened to physically harm another resident and was sent to the ER for evaluation. The DON acknowledged that this incident, which met the criteria for abuse reporting, was not reported to RIDOH as required by state law and facility policy.
Surveyors found that medications, including Trelegy Ellipta inhalers, Morphine Sulfate, and Lorazepam Intensol, were opened and not dated, and that Lorazepam was not refrigerated as required. Staff acknowledged these lapses in medication storage and labeling during interviews.
A resident with schizophrenia and moderate cognitive impairment, who was dependent on staff for supervision, successfully eloped from the facility after repeatedly expressing a desire to leave. Despite prior documentation of elopement risk and a physician order restricting leave, the facility did not reassess the resident's risk or update the care plan after the incident, and failed to complete required assessments or documentation.
A facility failed to notify a resident and their representative of a transfer or discharge, including the reasons for the move, in writing and in a language and manner they understand. The resident, with severe cognitive impairment and diagnoses of violent behaviors and dementia, was transferred to the hospital following an alleged interaction and subsequently discharged. The facility could not provide evidence of the required notification during a surveyor interview.
A facility failed to provide a resident or their representative with written notification of the bed-hold policy during a hospital transfer. The resident, with severe cognitive impairment and a history of violent behaviors, was transferred following an interaction with another resident. The facility's Administrator and DON could not provide evidence of the required notification.
A facility failed to allow a resident to return after hospitalization, violating bed-hold policy. The resident, admitted since 2019 with dementia and violent behaviors, was sent to the hospital for evaluation after an incident. Diagnosed with COVID-19 and a UTI, the resident was discharged without a 30-day notice. The Administrator and DON confirmed the decision not to allow the resident's return, despite the lack of documentation supporting this action.
The facility was found deficient in food safety standards as hot food items were served below the required temperature, and there was no evidence of reheating to meet policy standards. Additionally, a dietary aide was observed handling equipment in the kitchen without a hair restraint, contrary to facility policy. These issues were identified during a survey following a complaint about food temperatures and staff not wearing hairnets.
The facility failed to provide food and drinks at an appetizing temperature for several residents. A community complaint highlighted that hot food items were served cold. Residents reported ongoing issues with cold food, leading some to source meals externally or reheat them personally. A test tray confirmed that food temperatures were below the facility's policy requirements, with staff acknowledging the failure to maintain appropriate temperatures.
A resident with moderately impaired cognition allegedly touched another resident with severely impaired cognition inappropriately in a sunroom. The incident was witnessed by a cognitively intact resident who intervened and reported it to staff. The police were involved, and the resident was arrested for second-degree sexual assault.
Multiple residents experienced significant medication errors due to transcription mistakes and failure to follow physician orders. A resident with hypertension received Lasix despite an order to hold it, while another with gastric ulcer and diabetes received incorrect dosages of metronidazole and missed metformin doses. A resident with seizures missed doses of Valproic Acid, and a resident with heart failure received an incorrect total dose of Lasix. Staff acknowledged these errors during surveyor interviews.
A facility failed to create a comprehensive care plan for a resident identified as a smoker, despite assessments confirming nicotine dependence. The DON acknowledged the oversight during an interview.
A resident with severe morbid obesity and muscle weakness, dependent on staff for bathing, did not receive scheduled showers as ordered. Despite a care plan and physician's order for biweekly showers, staff interviews and surveyor observations revealed the resident had not been showered since May. The primary NA admitted to not providing showers, and facility management could not provide evidence of compliance with the care plan.
A facility failed to document the administration of oxygen for a resident with lung cancer and pneumonia, as required by their policy and professional standards. Despite physician orders specifying oxygen flow rates and conditions, records did not consistently reflect the amount of oxygen administered, even when the resident was observed on oxygen. The resident's physician expected proper documentation, highlighting a deficiency in respiratory care practices.
The facility failed to follow physician's orders for two residents. One resident did not receive scheduled laboratory tests for Valproic Acid levels, and another resident did not have daily weights recorded or a psychiatric consult completed. The DNS could not provide evidence of these actions during the surveyor interviews.
The facility failed to maintain accurate medical records for two residents. One resident did not receive a shower and wound treatment as documented, and another resident did not have a psychiatric evaluation as ordered. Staff interviews confirmed the inaccuracies in documentation.
Failure to Manage Escalating Aggression Leading to Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident, Resident ID #1, from abuse by another resident with a known history of escalating aggression, Resident ID #2. Resident ID #1 was admitted in October 2025 with diagnoses including paranoid schizophrenia and adjustment disorder with mixed anxiety and depressed mood, and had a BIMS score of 14/15, indicating intact cognition. On 4/27/2026, progress notes documented that Resident ID #1 was on the receiving end of a physical altercation with another resident and was found with a deep bleeding abrasion to the left eyebrow. A subsequent nursing note described a new laceration to the left eyebrow measuring 0.5 cm by 2.0 cm by 0.1 cm, related to a resident-to-resident incident, for which wound closure strips were applied. Resident ID #1 requested police involvement and a police report, and refused transfer to the hospital for sutures. Resident ID #2 had been admitted in December 2024 with multiple psychiatric and behavioral diagnoses, including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed a BIMS score of 13/15 and documented both physical and verbal behaviors during the look-back period. Progress notes over several months recorded a pattern of escalating aggressive and threatening behaviors: on 9/13/2025, Resident ID #2 threatened to slit another resident’s throat and made additional threats toward staff; on 11/7/2025, the resident was involved in a verbal dispute with raised voice, name-calling, and verbal threats; on 12/28/2025, after another resident struck Resident ID #2 with a helmet, Resident ID #2 was overheard threatening to kill that resident if touched again. On 2/21/2026, the on-call provider documented that Resident ID #2 attacked a roommate with a cane over TV volume and required ER transfer for psychiatric evaluation. Subsequent notes on 3/9/2026 and 4/10/2026 described the resident throwing poker chips on the floor, yelling and swearing at staff and residents, and throwing a lunch plate across the nurses’ station at a nursing assistant due to dissatisfaction with portion size. Despite this documented pattern, the care plan for Resident ID #2, dated 1/16/2025, only indicated a behavior problem of being verbally aggressive toward staff with resident-to-resident altercations on 12/28/2025, 2/21/2026, and 4/27/2026, and record review failed to show added interventions to mitigate the risk of physical aggression toward other residents after the 2/21/2026 cane attack and the object-throwing incidents on 3/9/2026 and 4/10/2026. A psychiatric evaluation on 4/23/2026 recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order entered on 4/24/2026 specified trazodone 25 mg twice daily as needed only for insomnia, and record review did not show that agitation and anxiety were included as indications for use. During interviews, the RNP and the DON stated it was their expectation that agitation and anxiety would have been included in the trazodone order, and the DON was unable to provide evidence that the care plan had been updated with interventions to address Resident ID #2’s physically aggressive behaviors documented on 2/21/2026, 3/9/2026, and 4/10/2026. On 4/27/2026, the DON documented that Resident ID #2 was ambulating down the hall toward his/her room while Resident ID #1 was walking in the opposite direction, and the two residents began a verbal dispute. Before staff could intervene, Resident ID #2 used his/her cane to make contact with Resident ID #1, resulting in the eyebrow laceration that required steri-strips and ongoing wound treatment. A police incident report recorded that Resident ID #1 stated being struck with a walking cane, wanted to press charges, and that Resident ID #2 admitted to striking Resident ID #1, leading to an arrest on one count of felony assault with a dangerous weapon. The facility’s failure to assess, monitor, and implement effective interventions for Resident ID #2’s known and escalating aggressive behaviors, including failure to update the care plan after prior incidents and failure to fully implement psychiatric recommendations, resulted in this resident-to-resident altercation and injury, and the report states that this failure placed Resident ID #1 and other residents at risk of serious physical and psychosocial harm.
Failure to Implement Psychiatric Recommendations and Update Behavior Care Plan Leading to Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health services and care planning for a resident with a documented history of psychiatric conditions and aggressive behaviors. The resident was admitted in December 2024 with diagnoses including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed intact cognition with a BIMS score of 13/15 and documented physical and verbal behaviors during the look-back period. Over time, multiple behavioral incidents were recorded, including threats to slit another resident’s throat during a smoking session, verbal disputes with name-calling and threats, and a statement to another resident that if touched again the resident would be killed. Further documentation showed escalating behaviors, including an incident where the resident attacked a roommate with a cane over television volume and required ER transfer for psychiatric evaluation, throwing poker chips and yelling when not winning at Bingo, causing the roommate to avoid the shared bathroom due to inappropriate comments and frustration over the light being turned on at night, and throwing a lunch plate across the nurses’ station at a nursing assistant over portion size. The care plan, initiated in January 2025 for verbal aggression and resident-to-resident altercations, did not contain added interventions to address the resident’s physically aggressive behaviors toward others after the incidents on 2/21/2026, 3/9/2026, and 4/10/2026. The DNS later could not provide evidence that the care plan had been updated with interventions to mitigate the risk of these physically aggressive behaviors or to guide staff in ensuring the safety of other residents. On 4/23/2026, a psychiatric evaluation recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order dated 4/24/2026 implemented trazodone 25 mg twice daily as needed for insomnia only, and the record lacked evidence that agitation and anxiety were included as indications for use as recommended by the consulting psychiatrist. Both the RNP and the DNS stated it was their expectation that the trazodone order would have included agitation and anxiety. Following this incomplete implementation of the psychiatric recommendation and the lack of updated behavioral interventions in the care plan, a resident-to-resident altercation occurred on 4/27/2026 in which the resident struck another resident with a cane, causing a laceration to the left eyebrow that required closure with steri-strips and ongoing wound treatment.
Failure to Provide Ordered Foley and Suprapubic Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services related to urinary catheter care for three residents with indwelling catheters. One resident with a Foley catheter was admitted with urinary retention and neurogenic bladder and had physician orders for monthly Foley catheter changes and as-needed changes. Treatment Administration Records showed the monthly change order documented as not applicable or refused, and an order directing the primary team to determine if the Foley should be exchanged by urology for discolored, cloudy, and blood-tinged urine was signed as completed. However, there was no evidence that urology was contacted or that an appointment was scheduled, and the Foley catheter had not been exchanged since a hospital procedure months earlier. A community complaint later alleged that this resident arrived at the emergency room with a crusted Foley catheter, erosion of the urinary meatus, significant urinary retention, and foul-smelling urine. The deficiency also includes failure to follow physician orders for suprapubic (SP) catheter exchanges for a second resident with external genitalia, head, and neck malignancies. This resident had a care plan requiring SP catheter changes per physician orders and an order to call and set up an appointment with urology for an SP catheter exchange, which was documented as completed daily on the Treatment Administration Records. A continuity of care document showed that urology had exchanged the SP catheter and indicated that the next SP exchange was due in four weeks at the facility. Record review did not show any evidence that the SP catheter had been exchanged since that urology visit, despite the nurse practitioner’s expectation that the exchange would occur in the facility if not done by urology and the ADNS’s statement that nursing staff were competent to perform SP tube exchanges. For a third resident with a flaccid neuropathic bladder and an SP catheter, the care plan required SP catheter changes per physician orders, and an order specified that SP catheter exchanges were to be completed at urology. A continuity of care document showed that urology had exchanged the SP catheter and scheduled a follow-up appointment for an annual check-up and SP catheter exchange. The urology receptionist reported that the resident did not attend the scheduled follow-up appointment and had not been seen since the prior exchange. The ADNS was unable to provide evidence that the resident had any urology appointments after that date or that the SP catheter had been exchanged according to the physician’s order.
Failure to Address Progressive Mobility Decline and Contractures
Penalty
Summary
The facility failed to ensure that a resident who was admitted without limited ROM did not experience a reduction in ROM and mobility, resulting in severe bilateral lower extremity contractures. The resident had diagnoses including dementia, left-sided hemiplegia, left-sided hemiparesis, and bilateral lower leg contractures. MDS assessments showed a progressive decline in function over time, with the resident moving from being able to ambulate up to 150 feet to no longer being able to ambulate any distance, and later being dependent for bed mobility, transfers, and ambulation. A quarterly MDS also documented severe cognitive impairment and non-ambulatory status with dependence for bed mobility. A progress note from an RNP documented that the resident was “starting to have contractures” and ordered a PT evaluation and treatment, but the record did not show that PT completed an evaluation or provided treatment until approximately 10 months later, after the surveyor raised the concern. A PT document completed after the surveyor’s observation showed impaired ROM in both lower extremities, poor tolerance to PROM, increased tone, and discomfort. The resident’s care plan was revised to reflect impaired mobility and dependence with bed mobility, transfers, ambulating, and all ADLs, but the record did not show timely PT intervention after the physician order. Surveyor observations on multiple dates showed the resident in bed with bilateral lower extremity contractures, including one observation where the right heel was pressed up against the buttock. Staff acknowledged the contractures and stated they were unaware when they developed. The resident’s family member stated the resident had been ambulatory on admission and was now contracted, and that therapy had not been received to address the contractures. Staff and the DON acknowledged the resident developed the contractures at the facility and could not provide evidence of interventions to prevent or address them.
Failure to Address Severe Weight Loss and Nutrition Needs for Pressure Ulcer
Penalty
Summary
The facility failed to ensure a resident with severe cognitive impairment, a history of fracture of the neck, dementia with psychotic disturbance, and a stage 4 pressure ulcer maintained acceptable nutritional status and received timely nutrition-related assessment and interventions. The resident’s record showed a significant weight loss from 160.4 pounds on 4/1/2025 to 142.1 pounds on 7/2/2025, a loss of 18.3 pounds or 11.4%. The facility policy required reweighing residents with significant weight changes within 48 hours, notifying the physician, dietitian, DNS, and resident representative, reviewing the diet, and starting weekly weights, but the record did not show a reweigh after the 7/2/2025 weight loss or evidence of new interventions for the severe weight loss. The resident had been receiving a house supplement ordered twice daily, which was reduced to once daily after a nutrition note stated weight was stable and intake was good. Although the resident consumed 100% of the ordered supplement for 26 of 28 opportunities in August 2025, the record did not show that the RD assessed the resident for the July weight loss until 8/26/2025. During interview, the NP stated she was aware of the weight loss in July, thought dietary was following the resident, and acknowledged there were no interventions in place to address the weight loss. She stated she would have increased the supplement back to twice daily and ordered Remeron to improve intake. The resident also had a right buttock pressure ulcer that was identified as unstageable and later documented as a stage 4 pressure ulcer. A wound progress note requested an RD consultation and stated to optimize nutrition, but the record did not show that the RD assessed the resident’s nutritional needs related to the wound until 8/26/2025, about two months after the wound was identified. The NP stated she would have expected dietary to conduct a consult when the wound was identified, and the DNS stated she expected new interventions for the severe weight loss and was unable to provide evidence that a dietary consult for the wound had been completed until 8/26/2025.
Food Storage and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and distributed in accordance with professional standards for food service safety in the main kitchen and in 4 of 4 kitchenettes observed. In the walk-in refrigerator, three containers of fresh strawberries and one container of fresh blueberries were observed with white fuzzy matter and no discard date. In the walk-in freezer, one open bag of sausage patties containing approximately 20 patties had no label or discard date. The Assistant Food Service Director acknowledged the fruit should have been thrown away and the sausage patties should have been labeled with a discard date. In the 1st, 2nd, and 3rd floor kitchenettes, opened bags of cereal were observed partially full without labels or discard dates. In the 4th floor kitchenette, a covered warmer plate containing biscuits, an egg omelet, two fried eggs wrapped in a napkin, and a cup of oatmeal was found in an upper cabinet above the top shelf. Staff interviewed after each observation acknowledged the items were not properly labeled or stored and should not have been placed as observed. In the main kitchen, a Dietary Aide was observed scraping food off dirty dishes with bare hands, then rinsing her hands in the 3-bay sanitizer sink instead of the handwashing sink before touching clean bins and resuming dish scraping.
Lack of QAPI Documentation for Significant Weight Loss PIP
Penalty
Summary
The facility failed to maintain documentation and demonstrate evidence of its ongoing QAPI program related to a performance improvement project involving significant weight loss. Review of the 2025 QAPI binder showed that a PIP was in place for significant weight loss, but further record review did not reveal documentation showing implementation of the plan or evaluation of corrective actions or performance improvement activities related to that PIP. During interview on 8/28/2025 at 1:00 PM, the Administrator and DON were unable to provide evidence of documentation showing monitoring and auditing of data related to the facility’s QAPI plan for significant weight loss.
Failure to Obtain Heart Rate Before Metoprolol Administration
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality when it did not follow the parameters of a physician's order for Metoprolol Succinate Extended Release for one resident. The resident was admitted in July 2025 with diagnoses including high blood pressure and heart failure. A physician's order dated 7/3/2025 directed Metoprolol Succinate Extended Release 50 mg by mouth daily, with instructions to hold the medication for a systolic blood pressure of less than 100 and/or a heart rate of less than 60. Review of the July and August 2025 Medication Administration Records did not show evidence that the resident's heart rate was obtained before Metoprolol was administered. During interview, the RN acknowledged that the order did not include documentation of the resident's heart rate and could not provide evidence that the heart rate was obtained before the medication was given in July and August 2025. The DON stated that she would expect the Metoprolol order to be followed and that the resident's heart rate would be obtained prior to administration.
Failure to Provide Pressure Ulcer Care and Offloading
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for two residents with pressure ulcers. Resident #4, admitted with diagnoses including dementia with psychotic disturbance and a stage 4 pressure ulcer of the right buttock, was noted on 6/21/2025 to have redness and an open area in the right trochanter area during care. The NP ordered cleansing, a dry dressing, and pressure off-loading every 2 hours, and the wound was later assessed by the Wound Nurse with treatment changes. Wound provider notes from 6/26/2025 through 8/21/2025 documented an unstageable pressure ulcer of the right inferior buttock with slough, later increased measurements, odor, erythema, and purulent drainage, and repeated recommendations for a dietary consult. Record review showed the RD did not complete a nutritional consult until 8/26/2025, about two months after the wound was identified and after repeated wound provider recommendations for dietary consultation. The resident’s wound-related dietary orders were not implemented until 8/27/2025, including ascorbic acid, zinc, and Prostat Extra Protein. During interview, the RD acknowledged awareness of the stage 4 pressure ulcer through interdisciplinary meetings but stated she failed to complete the nutritional assessment until 8/26/2025. The DNS was unable to provide evidence that the dietary consult had been completed earlier. Resident #99, admitted with dementia, left-sided hemiplegia, left-sided hemiparesis, and bilateral lower leg contractures, was assessed as non-ambulatory and dependent with bed mobility. The care plan identified a risk for pressure injury and directed staff to offload both heels with booties or pillows as tolerated. Record review documented prior pressure injuries including a new DTI on the right foot, reddened and non-blanchable areas on the right heel and right lateral foot, an unstageable pressure wound to the left medial heel, and pressure ulcers on both heels. Surveyors observed the resident lying in bed on multiple occasions without booties and without pillows under the lower extremities as care planned, and a Unit Manager observed severe contractures with the right heel pressed against the buttock. A CNA stated she did not put booties on the resident after care and indicated the resident no longer uses booties; the Unit Manager acknowledged the resident was not wearing booties and did not have pillows under the lower extremities.
Failure to Obtain Ordered CBC and CMP Monitoring
Penalty
Summary
The facility failed to obtain ordered laboratory services for Resident ID #2, who was readmitted in April 2025 with a diagnosis including sepsis. The resident had an active physician order starting 4/11/2025 for a CBC and CMP every Thursday, but the record did not show that these labs were obtained on 7/3, 7/10, 7/17, 7/25, 7/31, 8/7, and 8/21/2025, meaning the resident did not receive the ordered lab work on 7 of 9 opportunities. During interview, an RN stated the order had been entered incorrectly in the electronic medical record so it did not alert the nurse to complete the lab slip, which resulted in the CBC and CMP not being obtained as ordered. The DON also acknowledged that the lab work was not obtained as ordered on those dates.
Insufficiently Trained Dietary Staff Failed to Properly Test Dish Machine Sanitizing Temperatures
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out food and nutrition services related to testing the water temperature of the main dishwashing machine to ensure proper sanitization. Record review of the facility’s mechanical ware washing policy stated that the dietary manager should ensure staff know where the machine requirements, temperature logs, and test strips or thermometer are located, and that the internal temperature of the sanitizing cycle should be tested and logged before washing dishes from each meal. The dish machine manual also stated that for high-temperature sanitizing, the temperature at the manifold must reach a minimum of 180 F, and if color-changing tapes are used, only 165 F labels should be used. During observation, the Assistant Food Service Director placed a bowl on a dish rack through the dish machine, then took the temperature of water collected in the bowl with a thermometer, which read 164 F. The machine gauge showed 161 F on the wash cycle and 175 F on the final rinse, and when a second test cycle was run, the gauge read 182 F for the final rinse. During interview, the AFSD stated he obtained the water temperature by dipping a thermometer into a cup of water collected from the wash cycle, believed the machine was probably high temperature because he did not see chemicals, and was unaware that temperature test strips needed to be used in the manifold. Other dietary staff stated they did not test the dish machine temperatures and were unaware of how to perform the procedure, while a Dietary Cook stated the DAs were responsible for testing the machine. The AFSD was later observed dipping a temperature test strip into a cup of water from the dish machine cycle and then attempting to place a test sticker on a wet plate, and he acknowledged that he did not know the proper procedure to test the water temperature.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported to the Rhode Island Department of Health (RIDOH) as required by state law and facility policy. Specifically, a resident with diagnoses including dementia and anxiety disorder, who was cognitively intact according to a recent assessment, threatened to physically harm another resident. This incident was documented in a progress note, and the resident was subsequently sent to the emergency room for evaluation and admitted. Despite the facility's policy requiring immediate reporting of suspected abuse to the Director of Nursing and RIDOH, the Director of Nursing acknowledged during a surveyor interview that the incident was not reported to RIDOH. The failure to report the allegation of abuse in a timely manner constituted noncompliance with both state regulations and the facility's own procedures.
Failure to Properly Store and Label Medications
Penalty
Summary
Surveyor observations revealed that drugs and biologicals were not stored and labeled according to professional standards in two of four medication carts inspected. Specifically, two Trelegy Ellipta inhalers were found opened and undated, despite manufacturer instructions requiring disposal six weeks after opening. Additionally, Morphine Sulfate and Lorazepam Intensol oral suspension were found opened and undated, with the Lorazepam not stored in the required refrigerated conditions. The pharmacy label and manufacturer instructions for these medications specify discard dates and storage requirements that were not followed. Staff present during these observations, including a Certified Medication Technician, an LPN, and an RN, acknowledged the deficiencies when interviewed by surveyors. The Director of Nursing Services also confirmed that medications should be dated when opened and that Lorazepam should be refrigerated. These findings were consistent with a community complaint alleging improper medication storage and administration.
Failure to Assess and Intervene After Resident Elopement
Penalty
Summary
A resident with a diagnosis of schizophrenia and moderately impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 9 out of 15, was admitted to the facility and required supervision for ambulation and dressing. Despite a physician order prohibiting the resident from taking a leave of absence, and documentation that the resident was an elopement risk and required supervision for smoking, the facility failed to reassess the resident's elopement risk after multiple documented behaviors indicating a desire to leave, including repeated requests to go home and expressing a strong desire to return home. The resident ultimately left the facility unsupervised and traveled to a previous residence, with the facility only learning of the elopement after being contacted by the other location. Following the resident's return, the facility did not perform an elopement assessment or develop a care plan with interventions to minimize further risk, as required by its own policy. Progress notes and staff interviews confirmed that no elopement evaluation or AMA discharge documentation was completed after the incident, and the Director of Nursing and Administrator acknowledged these omissions. The facility's failure to identify and address the resident's increased risk for elopement, and to implement appropriate interventions after the event, resulted in a deficiency related to inadequate supervision and accident prevention.
Failure to Notify Resident and Representative of Transfer or Discharge
Penalty
Summary
The facility failed to notify a resident and their representative of a transfer or discharge, including the reasons for the move, in writing and in a language and manner they understand. This deficiency was identified for a resident who was transferred to the hospital and subsequently discharged from the facility. The resident, who had been admitted in July 2019 with diagnoses of violent behaviors and dementia, was involved in an alleged resident-to-resident interaction that led to their transfer to the emergency room on January 14, 2025. The record review did not reveal any evidence that the facility provided the required notification to the resident or their representative. During an interview with the Administrator and the Director of Nursing, they were unable to provide documentation that the necessary notifications were made. The resident's severe cognitive impairment, as indicated by a Quarterly Minimum Data Set Assessment, further underscores the importance of proper communication with their representative.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification to a resident or their representative regarding the bed-hold policy during a transfer to the hospital. The deficiency was identified through a record review and staff interviews, which revealed that the facility did not provide the required written notice specifying the duration of the bed-hold policy at the time of the resident's transfer. This oversight was noted for a resident who was transferred to the emergency room following an alleged interaction with another resident. The resident, who was admitted to the facility in July 2019 with diagnoses of violent behaviors and dementia, was documented as having severe cognitive impairment. The complaint, submitted to the Rhode Island Department of Health, alleged that the resident was not allowed to return to the facility and did not receive a 30-day notice as required. During an interview, the facility's Administrator and Director of Nursing were unable to provide evidence of the required written notification to the resident or their representative regarding the bed-hold policy.
Facility Fails to Allow Resident Return Post-Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after a hospitalization, violating the bed-hold policy. The resident, who had been living in the facility since July 2019, was transferred to the hospital for a psychological evaluation following an alleged interaction with another resident. The hospital diagnosed the resident with COVID-19 and a urinary tract infection, which can cause agitation in the elderly. Despite these circumstances, the facility discharged the resident on the same day as the hospital transfer, without providing the required 30-day notice. Surveyor observations confirmed that the resident's room was vacant following the transfer. During interviews, the Administrator and the Director of Nurses admitted that they decided not to allow the resident to return to the facility. This decision was made despite the absence of documentation supporting the resident's discharge or any evidence that the resident was given the opportunity to return after hospitalization, as required by regulations.
Deficiencies in Food Safety and Hair Restraint Compliance
Penalty
Summary
The facility failed to adhere to professional standards of food service safety during meal preparation, storage, and distribution. During a surveyor observation, it was noted that the temperatures of hot food items on the steam table were below the required holding temperature of 135 degrees Fahrenheit. Specifically, mashed potatoes were at 129.2 F, chicken at 128.3 F, and burger patties at 125.4 F. The facility's policy mandates that if food is below 135 F, it should be reheated to at least 165 F for a minimum of 15 seconds before serving. However, there was no evidence that these food items were reheated to meet the policy requirements. The Food Service Director acknowledged that the food should have been reheated according to the facility's policy. Additionally, the facility did not comply with the Rhode Island Food Code regarding the use of hair restraints in the kitchen. During an observation, a dietary aide was seen handling equipment in the main kitchen without wearing a hair restraint, which is against the facility's policy. The Food Service Director confirmed that all staff are expected to wear hair restraints while working in the kitchen. These deficiencies were identified during a survey following a community-reported complaint about food being served at unappetizing temperatures and staff not wearing hairnets.
Failure to Maintain Appropriate Food Temperatures
Penalty
Summary
The facility failed to provide food and drinks that are palatable, attractive, and at an appetizing temperature for four out of five residents reviewed. A community complaint was submitted to the Rhode Island Department of Health, alleging that hot food items were being served cold and at an unappetizing temperature. The facility's policy requires hot foods on room trays to be at 120°F or greater to promote palatability. However, surveyor interviews with residents revealed ongoing issues with cold food. Resident ID #2, admitted in September 2021 with type II diabetes mellitus, reported that hot food items have always been cold since admission. Resident ID #3, admitted in October 2024 with hypertension, stated that the food served within the last week was cold and not palatable, leading to sourcing meals from outside the facility. Resident ID #4, readmitted in August 2024 with depression, mentioned having to microwave food daily due to it being served cold. Resident ID #5, admitted in September 2024 with gastro-esophageal reflux disease, refused to eat breakfast because it was not hot and had to heat the food personally. A test tray ordered by the Unit Manager, Staff A, showed that the food temperatures were below the facility's policy requirements. The mashed potatoes were at 112.7°F, chicken at 106.1°F, and vegetables at 117.8°F. Staff A acknowledged that the food failed to hold the temperature from the steamer and expected temperatures closer to 135°F. The Food Service Director also expected the food to be at least 120°F or higher, per the facility policy. These findings indicate a failure to maintain appropriate food temperatures, leading to dissatisfaction among residents and non-compliance with the facility's policy on food service temperatures.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving two residents. Resident ID #1 reported that Resident ID #2 entered their room and joined them in bed without consent. Further allegations were made that Resident ID #2 sat on Resident ID #1's face while fully clothed, leading Resident ID #1 to retaliate by touching Resident ID #2's genitals. Resident ID #1 was admitted with mild neurocognitive disorder and had a BIMS score indicating moderately impaired cognition. Resident ID #2, with a history of dementia and schizophrenia, had a BIMS score indicating severely impaired cognition, making it difficult for surveyors to interview them. The incident was witnessed by another resident, Resident ID #4, who reported seeing Resident ID #1 touch Resident ID #2's thigh and move their hand towards the upper thigh in the sunroom. Resident ID #4, who had no cognitive impairments, intervened and reported the incident to the facility staff. The police were involved, and Resident ID #1 was arrested for second-degree sexual assault. The facility's failure to prevent this incident and protect the residents from abuse constitutes a deficiency in their care standards.
Medication Errors Affect Multiple Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting four out of nine residents reviewed. Resident ID #111, who was admitted with hypertension and acute kidney failure, received Lasix despite an order to hold the medication for three days due to lab results. The medication was administered on three consecutive days in error. Resident ID #136, with a history of gastric ulcer and diabetes mellitus, received an incorrect dosage and frequency of metronidazole due to a transcription error, and missed 34 doses of metformin because the order was not transcribed. The errors were acknowledged by the staff involved during surveyor interviews. Resident ID #162, admitted with seizures, did not receive Valproic Acid on two occasions, and the provider was not notified of the missed doses. Staff acknowledged the oversight during interviews. Resident ID #186, with abnormal blood chemistry and heart failure, received an incorrect total dose of Lasix due to a failure to hold the 20 mg dose as ordered and an error in administering both 20 mg and 40 mg doses on the same day. The staff involved confirmed the administration errors during surveyor interviews, and the Director of Nursing Services was unable to provide evidence that the Lasix order was followed correctly.
Failure to Develop Comprehensive Smoking Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident identified as a smoker. The resident was admitted to the facility in May 2024 with a diagnosis that included nicotine dependence. A smoking assessment was completed upon both admission and re-admission, indicating the resident is a smoker. However, the facility did not create a comprehensive care plan for smoking as required by their policy. During an interview, the Director of Nursing Services acknowledged the resident's smoking status and the absence of a comprehensive care plan addressing this issue.
Failure to Provide Scheduled Showers to Dependent Resident
Penalty
Summary
The facility failed to provide necessary services to a resident who was unable to carry out activities of daily living, specifically regarding scheduled showers. The resident, admitted in June 2023 with severe morbid obesity and generalized muscle weakness, was dependent on staff assistance for bathing and showering. A care plan dated January 2024 confirmed the resident's dependency on staff for self-care and mobility, including showers. A physician's order from July 2024 specified biweekly showers on Mondays and Thursdays during the day shift. However, surveyor observations on July 24 and 25, 2024, noted a strong odor of urine in the resident's room, and the resident reported not having received a shower since moving to the unit in May 2024. Interviews with staff revealed further deficiencies in care. The resident's primary Nursing Assistant (NA), Staff B, admitted to not providing the resident with a shower since May 2024, despite being assigned to the resident on specific dates when showers were ordered. Staff B also acknowledged that the shower chair was not broken, contradicting the reason given to the resident for not receiving showers. Additionally, the unit manager, an LPN, and the Director of Nursing Services were unable to provide evidence that the resident received showers as ordered, indicating a systemic failure in adhering to the care plan and physician's orders for the resident's hygiene needs.
Failure to Document Oxygen Administration
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident with a history of lung cancer, shortness of breath, and pneumonia. The deficiency was identified through surveyor observation, record review, and staff interviews. According to the facility's policy and the Lippincott Manual of Nursing Practice, documentation of oxygen administration should include the date, time, amount, and method of administration, as well as the resident's condition before and after therapy. However, the facility's records did not consistently document the amount of oxygen administered to the resident on several occasions, despite the resident being observed on oxygen during surveyor visits. The resident had a physician's order for oxygen administration, specifying a flow rate of 2-4 liters via nasal cannula, with instructions to titrate as needed to maintain pulse oximetry levels above 88% on room air. Despite these orders, the facility's Treatment Administration Record for July 2024 failed to document the administration of oxygen on specific dates, as required by the facility's policy. During an interview, the resident's physician expressed the expectation that staff should document the date, time, and amount of oxygen administered each time it is given. This lack of documentation represents a failure to adhere to the facility's policy and professional standards of practice for respiratory care.
Failure to Follow Physician's Orders for Laboratory Tests and Consults
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice by not following physician's orders for two residents. Resident ID #162, who was admitted with a seizure disorder, had a physician's order for Valproic Acid and required bloodwork, including a comprehensive metabolic panel (CMP) and Valproic Acid level, every six months starting on 6/12/2024. However, the laboratory results for these tests were not obtained as ordered, and the Director of Nursing Services (DNS) could not provide evidence of the completed laboratory work during the surveyor interview. Resident ID #241, admitted with cirrhosis of the liver, ascites, and a history of depression, had a physician's order for daily weights and a psychiatric consult. The resident's weights were not recorded on two specific dates, and there was no evidence that the psychiatric consult was completed. The DNS acknowledged the failure to obtain daily weights and could not provide evidence of the psychiatric evaluation during the surveyor interview. The resident's physician expressed the need for a psychiatric evaluation before starting any medications.
Inaccurate Medical Record Documentation for Resident Care
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with professional standards for two residents. For Resident ID #111, discrepancies were found in the documentation of shower schedules and wound treatment. The resident was admitted with diagnoses including morbid obesity and generalized muscle weakness. The physician's orders specified a weekly shower schedule and the application of a skin protectant cream to a wound on the left posterior thigh. However, the Nursing Assistant assignment log showed a different shower schedule, and the Treatment Administration Record inaccurately indicated that the resident received a shower and wound treatment on a specific date. Interviews with the Nursing Assistant and Registered Nurse involved confirmed that the documented care was not provided. For Resident ID #241, the facility failed to provide evidence of a psychiatric evaluation as ordered. The resident, admitted with cirrhosis of the liver, ascites, and a history of depression, had a physician's order for a psychiatric consultation. Although a form indicated that the psychiatric provider signed off on completing the consult, there was no evidence that the evaluation occurred. An interview with the Director of Nursing Services revealed the absence of documentation to support that the psychiatric evaluation was conducted, and subsequent communication with the psychiatric provider confirmed that the evaluation was not completed.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 631 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Providence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elmhurst Rehabilitation And Healthcare Center | 0.5 mi | ★★★★★ | 10 | 1 |
| Golden Crest Nursing Centre | 1.4 mi | ★★★★★ | 8 | 0 |
| Adviniacare Providence Dodge Rehab Center, Llc | 2 mi | ★★★★★ | 4 | 0 |
| Adviniacare Summit Commons, Llc | 2 mi | ★★★★★ | 15 | 2 |
| Jeanne Jugan Residence | 2.2 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.