Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Mount St Rita Health Centre during CMS and state inspections, most recent first.
The facility failed to maintain a sanitary and comfortable environment when surveyors observed multiple brown-stained ceiling tiles on two floors, including in main hallways, above a resident room doorway, above a utility room doorway, and in the hallway and doorway areas leading to shower rooms. These findings followed a community complaint alleging plumbing problems, leaking ceilings and heating systems, and widespread water stains in ceiling tiles. During the survey, the Maintenance Director acknowledged the stained tiles and that they required replacement.
A resident with a history of falls and mobility limitations exited the facility unsupervised during severe weather, after previously demonstrating attempts to leave. The care plan was not updated to address wandering or elopement risk, and staff were unaware of the resident's absence until the individual was found outside with frostbite and injuries, requiring hospitalization. The facility failed to provide adequate supervision and did not revise the care plan following earlier incidents.
A resident with DM and insulin use had repeated blood glucose readings above the ordered parameter, but the record did not show provider notification for most of those events. Another resident with dementia had a physician order to offload both heels while in bed, yet surveyors observed the heels resting directly on the mattress on multiple occasions, and an LPN and the DON acknowledged the order was not being followed.
Incomplete and Inaccurate Resident Record Documentation: A resident with a stage IV pressure ulcer had wound measurement orders documented as completed in the TAR, but the record did not show the measurements were actually obtained and documented. Another resident with dementia had an order to offload both heels in bed, yet surveyors observed the heels resting on the mattress while the TAR showed the task as completed. An LPN acknowledged the documentation and care did not match, and the DON could not provide evidence that records were complete and accurate.
Failure to provide ordered wound care and weekly wound monitoring for a resident with a stage IV coccyx pressure ulcer. During observation, an LPN changed gloves without hand hygiene, used a piece of calcium alginate with silver after placing it on unsterile packaging, and covered the wound with an island dressing instead of the ordered silicone border dressing. Records also showed missing weekly wound measurements and a skin assessment that listed the wound as not evaluated, and the TAR did not show one daily wound treatment was completed as ordered.
Incompetent wound care and failure to follow ordered dressing treatment. An LPN caring for a resident with a stage IV pressure ulcer did not perform hand hygiene after changing gloves, handled sterile wound material in an unsterile manner, and used an island dressing instead of the ordered silicone border dressing. The Staff Educator and DON confirmed the LPN had not completed the required clean dressing change competency.
Failure to follow contact precautions occurred when staff entered a resident's room without the required gown and gloves despite signage and a physician order for contact precautions related to conjunctivitis. The NA also exited with soiled gloves and accessed the clean PPE bin without hand hygiene, and the RN, IP, and DON confirmed the precautions and expected PPE use.
The facility failed to ensure proper care for a resident with dementia by not having an order for a wanderguard bracelet, despite the resident's risk for wandering. Additionally, two residents experienced changes in condition without timely provider notification. One resident with Alzheimer's developed pitting edema, and another with iron deficiency anemia showed bruising after a procedure, yet neither case was reported to the provider as required.
The facility failed to properly store and label medications, with expired drugs found on a medication cart and in medication rooms. LPNs acknowledged the expired medications, including vitamin supplements and Ativan Intensol. Additionally, ice accumulation was observed in medication storage fridges on all floors, with the DON unsure of the last defrosting.
A resident admitted with a pressure ulcer on the left heel did not receive necessary wound care for seven days due to an incorrectly transcribed treatment order. Required wound assessments and documentation were delayed until eleven days after admission, as confirmed by facility staff, including the wound nurse and DON.
A facility failed to implement an effective antibiotic stewardship program, leading to incorrect administration of Bactroban 2% for a resident. The medication, intended for a left heel wound, was applied to the nares for 11 days. The Infection Preventionist and DON acknowledged the error and the absence of an antibiotic timeout, highlighting deficiencies in monitoring and managing antibiotic use.
A resident receiving end-of-life care was administered an incorrect dose of morphine, receiving only half of the prescribed amount on two occasions. The error was confirmed by an LPN and the DON, who acknowledged the discrepancy between the administered dose and the physician's order.
Stained Ceiling Tiles and Unsanitary Environmental Conditions
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment for residents, staff, and the public, as evidenced by multiple stained ceiling tiles on two of three floors. A community complaint submitted to the state health department alleged serious plumbing issues, leaking ceilings and heating systems, and water stains throughout the building’s ceiling tiles. During a survey of the first floor, the surveyor observed a brown-stained ceiling tile approximately 6 inches long in the main hallway across from the chapel; another brown-stained tile spanning about 8 inches directly above the doorway to a resident room on the South unit; a brown-stained tile approximately 6 to 8 inches long above the doorway to a utility room on the South unit; and three adjacent ceiling tiles, each with circular brown stains 12 to 18 inches in diameter, in the hallway leading to the shower rooms on the South unit. On the second-floor South unit, the surveyor observed a ceiling tile with a semi-circular brown stain approximately 18 inches wide above the doorway to a shower room. During observations and an interview with the Maintenance Director, he acknowledged that these ceiling tiles were stained and needed to be replaced. No additional resident-specific clinical information or medical history was provided in relation to this deficiency.
Failure to Provide Adequate Supervision Resulting in Resident Elopement and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of falls, partial weight bearing status, and an amputation was able to exit the facility unsupervised during inclement weather. The resident had previously demonstrated attempts to leave the building, including an incident where the resident attempted to exit the facility and refused to return to the unit, but the care plan was not updated to address this behavior. There was no evidence that an elopement evaluation was completed after the initial incident, nor was the care plan revised to include interventions for wandering or elopement risk prior to the subsequent event. On the day of the incident, the resident exited the building in the early morning hours without staff knowledge, during a snowstorm with freezing temperatures. The resident fell outside after dropping a cane and was unable to get up, remaining outside for approximately an hour. The resident was found by staff after calling for help, presenting with significant frostbite and blisters on both hands, and was subsequently hospitalized for further evaluation and treatment. Staff interviews revealed that the resident was able to disengage the alarm system using the emergency exit button, and that staff were not aware of the resident's absence until the resident was discovered outside. The facility's policy required adequate supervision and individualized care planning for residents at risk of wandering or elopement. However, the resident's care plan did not reflect the risk behaviors observed, and staff, including the Administrator and DON, were unaware of the prior incident and did not implement additional supervision or interventions. The lack of timely assessment and care plan updates contributed to the resident's ability to leave the facility undetected, resulting in an unwitnessed fall and frostbite injuries.
Failure to Follow Physician Orders for Insulin Parameters and Heel Off-Loading
Penalty
Summary
The facility failed to ensure that treatment and care were provided in accordance with professional standards of practice for a resident with diabetes who had a physician’s order for Humalog insulin 16 units before meals and instructions to notify the provider if blood glucose was below 70 or above 350. Review of the resident’s November and December 2025 medication administration records showed multiple blood glucose readings above 350, including 411, 357, 383, 390, 362, 387, 373, 368, 392, and 351. The record did not show evidence that the physician was notified for 7 of the 10 occasions when the blood glucose was above the ordered parameter, and staff and the DON were unable to provide evidence that notification occurred for those instances. The NP stated that staff were expected to notify her when the resident’s blood glucose was above or below the ordered parameters. The facility also failed to follow a physician’s order for another resident to offload both heels while in bed. The resident, who had a diagnosis including dementia, had an order dated 11/8/2024 to offload the bilateral heels while in bed. During surveyor observations on three separate occasions, the resident was in bed with the heels resting directly on the mattress, showing that the heels were not offloaded. An LPN acknowledged that the heels were not offloaded and stated that they should be, and the DON also stated that the resident’s bilateral heels should have been offloaded while in bed per the physician’s order.
Incomplete and Inaccurate Resident Record Documentation
Penalty
Summary
Resident ID #11, who was readmitted with a diagnosis including a stage IV pressure ulcer, had physician orders on 10/10/2025, 10/24/2025, 11/7/2025, and 11/21/2025 to obtain coccyx wound measurements and document them in a progress note. Review of the October and November 2025 TAR showed these orders were documented as completed by an LPN, but the clinical record did not contain evidence that the wound measurements were actually obtained and documented on those dates. During interview, Staff B acknowledged documenting the orders as completed but was unable to provide evidence that the measurements were obtained as ordered. Resident ID #47, who was readmitted with a diagnosis including dementia, had a physician order dated 11/8/2024 to offload both heels while in bed every shift. Surveyor observations on 12/1/2025, 12/2/2025, and 12/3/2025 showed the resident in bed with both heels resting directly on the mattress, indicating they were not offloaded. The December 2025 TAR documented the heel-offloading order as completed for all shifts on 12/1 and 12/2, and Staff B acknowledged the heels were not offloaded and should have been. The DON was also unable to provide evidence that resident records were complete and accurately documented.
Failure to Provide Ordered Wound Care and Required Wound Monitoring
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for a resident with a stage IV coccyx pressure ulcer. The resident was readmitted to the facility in September 2023 with diagnoses including a stage IV pressure ulcer, and the care plan directed staff to administer ordered treatments and measure and document the wound weekly. A physician order dated 1/31/2025 directed cleansing the coccyx wound with Vashe, applying skin prep to the peri-wound, loosely packing calcium alginate with silver into the wound bed, and covering it with a silicone border dressing daily and as needed. During observation of wound treatment, an LPN removed the soiled dressing, cleansed the wound, changed gloves without performing hand hygiene, and placed a cut piece of sterile calcium alginate with silver on top of unsterile packaging before using it to pack the wound. He then covered the wound with an island dressing instead of the ordered silicone dressing and stated he always uses the island dressing because the facility does not have the silicone dressing, although the wound nurse stated the facility does have silicone dressings for this resident. Record review also failed to show weekly wound measurements and wound characteristic documentation for one of four opportunities in November 2025, and a weekly skin assessment documented the coccyx wound as not evaluated. The November 2025 TAR also failed to show the resident's daily wound treatment was completed as ordered on 11/27/2025.
Incompetent wound care and failure to follow ordered dressing treatment
Penalty
Summary
Staff failed to ensure that a licensed nurse was competent to perform clean dressing changes and follow infection control practices during wound care for a resident with a stage IV pressure ulcer. The resident was readmitted to the facility in September 2023 with a diagnosis including a stage IV pressure ulcer. A physician's order dated 1/31/2025 directed staff to cleanse the coccyx wound with Vashe, pat dry, apply skin prep to the peri wound, loosely pack calcium alginate with silver into the wound bed, and cover with a silicone border dressing daily and as needed. During observation of the wound treatment on 12/2/2025, an LPN removed the soiled dressing, discarded it, and cleansed the wound, then removed his gloves and put on new gloves without performing hand hygiene. He opened a sealed sterile package of calcium alginate with silver, cut a circle from the sheet, and placed it on top of the unsterile packaging before using it to pack the wound. He then covered the wound with an island dressing instead of the ordered silicone dressing. In interview, the LPN acknowledged not performing hand hygiene between glove changes and stated he always uses an island dressing because the facility does not have the silicone dressing, while the Wound Nurse stated the facility did have silicone dressings for the resident's wound. The Staff Educator and DON both stated the LPN had not completed a clean dressing change competency, and the DON was unable to provide evidence that he completed the required competency during orientation.
Failure to Follow Contact Precautions
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained when staff failed to follow contact precautions for Resident ID #18, who had a physician's order for contact precautions due to a bacterial infection of the right eye and a diagnosis including conjunctivitis. Facility policy required hand hygiene upon entering and exiting the room and required gowns and gloves for contact precautions, with PPE to be donned before entry and disposed of before exit. During surveyor observation, the resident's doorway displayed signage indicating contact precautions and directing staff to wear a gown and gloves before entering. A Nursing Assistant entered the room without a gown and gloves, then exited wearing soiled gloves and accessed the clean PPE bin to obtain a gown without performing hand hygiene. In interview, the Nursing Assistant acknowledged not wearing the required PPE and was unsure why the resident was on precautions. The RN confirmed the resident was on contact precautions for conjunctivitis, the Infection Preventionist stated staff should wear a gown and gloves each time they enter the room, and the DON was unable to provide evidence that the precautions were followed as required.
Deficiencies in Resident Care and Provider Notification
Penalty
Summary
The facility failed to ensure that Resident ID #56 received treatment and care in accordance with professional standards of practice regarding the use of a wanderguard bracelet. The resident, who was admitted with a diagnosis of dementia and resides on an unsecured unit, was identified as being at risk for wandering and elopement. Despite this, there was no evidence of an order for a wanderguard in the resident's medical record, nor were there orders to check the placement and function of the wanderguard as per the facility's policy. The resident exhibited wandering and exit-seeking behaviors on multiple occasions, and staff acknowledged the absence of necessary orders during the surveyor's observation and interviews. The facility also failed to notify the provider of a change in condition for Resident ID #60, who was admitted with Alzheimer's Disease. The resident developed pitting edema in both legs, which was documented in progress notes, but there was no evidence that the provider was notified until the surveyor brought it to the facility's attention. Staff interviews confirmed that the edema was a change in condition requiring notification, and the physician expected to be informed when the edema was first noted. Similarly, the facility did not notify the provider of a change in condition for Resident ID #280, who was admitted with iron deficiency anemia and had recently undergone a procedure involving stent placement. The resident developed bruising around the genitals and groin area, which was noted in progress notes, but there was no evidence of provider notification. Staff interviews revealed awareness of the bruising, and the physician expected to be informed when it was first observed.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles. During a surveyor observation of the 1st floor medication cart, several expired medications were found, including vitamin B complex, cranberry supplement, ferate tablets, aspirin, and a multivitamin. The Licensed Practical Nurse (LPN) present acknowledged that these medications were expired and should have been discarded. Additionally, in the 2nd and 3rd floor medication rooms, bottles of liquid Ativan Intensol were found to be opened and expired, with the LPNs on duty confirming the oversight. Furthermore, the surveyor observed an accumulation of ice in the medication storage fridges on all three floors. The LPNs acknowledged the presence of ice, and the Director of Nursing Services admitted uncertainty about the last defrosting of the freezers. The Director also expressed an expectation that staff should discard expired medications and maintain the freezers properly.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a newly admitted resident with a pressure ulcer, as required by professional standards of practice. The resident was admitted with a diagnosis of pressure-induced deep tissue damage on the left heel, which was documented in the hospital discharge paperwork as receiving daily wound treatment. However, upon admission to the facility, there was no evidence of wound care being provided to the resident's left heel until seven days later. Additionally, the required wound assessments, including measurements and documentation of the wound's condition, were not conducted until eleven days after admission. Interviews with facility staff revealed that the lack of treatment and documentation was due to an incorrectly transcribed treatment order. The Unit Manager, who is also the facility's wound nurse, acknowledged that the resident did not receive the expected wound care and assessments upon admission and weekly thereafter. The Director of Nursing Services confirmed that the resident's pressure wound should have been addressed and documented weekly, indicating a failure in the facility's wound care protocol adherence.
Failure in Antibiotic Stewardship and Medication Administration
Penalty
Summary
The facility failed to establish an Infection Prevention and Control Program (IPCP) that includes an antibiotic stewardship program with protocols and a system to monitor antibiotic use. This deficiency was identified during a review of records and staff interviews, specifically concerning a resident who was admitted with conditions including pressure-induced deep tissue damage of the left heel and peripheral vascular disease. The hospital discharge summary indicated an order for Bactroban 2% to be applied to a left heel wound, but the facility's treatment administration record showed that the medication was incorrectly applied to the resident's nares for 11 days. The Infection Preventionist and the Director of Nursing Services both acknowledged the error in medication administration and the lack of an antibiotic timeout, which is a critical component of the antibiotic stewardship program. The failure to perform an antibiotic timeout and the incorrect application of the medication highlight the facility's deficiency in monitoring and managing antibiotic use as per the established protocols.
Significant Medication Error in Morphine Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of morphine. The resident, who was receiving end-of-life care and had diagnoses including Alzheimer's disease and diabetes, was assessed by hospice and had their morphine dosage increased. The physician's order specified that the resident should receive 0.25 milliliters of morphine every hour as needed for shortness of breath or severe pain. However, on two occasions, the resident was administered only 0.125 milliliters of morphine, which is half of the prescribed dose. The error was confirmed during a surveyor interview with the LPN who administered the doses and the Director of Nursing Services. The LPN acknowledged administering the incorrect dose, and the Director of Nursing confirmed that the resident received the wrong amount of morphine, contrary to the physician's order. The narcotic logbook and medical records failed to provide evidence that the correct dosage was administered, highlighting a significant medication error in the resident's care.
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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.
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Nursing homes near Cumberland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woonsocket Health Center | 4.2 mi | ★★★★★ | 0 | 0 |
| Madonna Manor Nursing Home | 4.3 mi | ★★★★★ | 6 | 0 |
| Adviniacare Oakland Grove Llc | 4.5 mi | ★★★★★ | 12 | 0 |
| The Gardens At Cedarwood | 4.8 mi | ★★★★★ | 0 | 0 |
| Alliance Health At Maples | 5.2 mi | ★★★★★ | 6 | 0 |
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