Inspection Reports for Berkshire Place Nursing and Rehabilitation Center
RI, 02908
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Inspection Report
Follow-Up
Deficiencies: 0
Nov 4, 2025
Visit Reason
A follow-up survey was conducted to verify correction of previous deficiencies identified during a prior recertification and Life Safety Code survey.
Findings
All previous deficiencies were corrected, and no new deficiencies were identified. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 199
Capacity: 220
Deficiencies: 6
Sep 4, 2025
Visit Reason
A recertification survey and complaint investigation survey were conducted at Berkshire Place on 08/25/2025 through 08/28/2025 to determine compliance with federal regulations for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
The survey identified multiple deficiencies related to professional standards of care, pressure ulcer prevention and treatment, nutrition and hydration, laboratory services, staffing, food safety, and life safety code compliance. The facility failed to meet several regulatory requirements, including timely assessments, interventions, and documentation for residents, as well as compliance with emergency preparedness and fire safety standards.
Complaint Details
The visit was complaint-related as part of a recertification survey and complaint investigation conducted from 08/25/2025 to 08/28/2025. Specific complaints involved medication administration, pressure ulcer care, nutrition, laboratory services, staffing, food safety, and life safety code compliance. The complaint was substantiated based on the deficiencies identified.
Severity Breakdown
E: 4
G: 1
D: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Services provided did not meet professional standards of quality related to medication administration and vital sign monitoring. | E |
| Failure to prevent and treat pressure ulcers consistent with professional standards of practice. | E |
| Failure to maintain adequate nutrition and hydration status for residents. | G |
| Failure to provide or obtain laboratory services as ordered. | E |
| Insufficient dietary support personnel and failure to ensure food safety and sanitation. | D |
| Failure to maintain life safety code compliance including means of egress and sprinkler system maintenance. | D |
Report Facts
Capacity: 220
Census: 199
Deficiencies cited: 7
Weight loss percentage: 11.4
Inspection Report
Annual Inspection
Census: 199
Capacity: 220
Deficiencies: 11
Aug 26, 2025
Visit Reason
A recertification survey and complaint investigation were conducted to determine compliance with federal regulations for Long Term Care Facilities, including state licensure and emergency preparedness. Additionally, an annual Federal Life Safety Code survey was conducted.
Findings
The facility was found to have multiple deficiencies including failure to meet professional standards in medication administration, pressure ulcer treatment and prevention, nutrition and hydration maintenance, laboratory services, food safety, and life safety code compliance. Deficiencies were identified in clinical care, quality assurance, and facility safety systems.
Severity Breakdown
E: 3
SQC-H: 1
G: 1
D: 3
F: 3
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to ensure services provided met professional standards related to a physician's order for Metoprolol Succinate Extended Release for a resident. | E |
| Failure to provide care to prevent and heal pressure ulcers for residents with pressure ulcers. | E |
| Failure to ensure residents with limited range of motion did not experience further reduction in range of motion. | SQC-H |
| Failure to maintain acceptable nutritional and hydration status for residents, including failure to monitor weight loss and provide dietary consults timely. | G |
| Failure to provide or obtain laboratory services to meet residents' needs. | E |
| Failure to employ sufficient dietary support personnel with appropriate competencies and skills. | D |
| Failure to ensure food safety, including proper sanitization of dishwashing machines and proper food storage and labeling. | F |
| Failure to maintain an effective Quality Assurance and Performance Improvement (QAPI) program addressing significant weight loss and other quality issues. | F |
| Failure to maintain means of egress free of obstructions and properly marked exit doors. | D |
| Failure to maintain doors with self-closing devices in accordance with NFPA 101 Life Safety Code. | D |
| Failure to maintain automatic sprinkler system and dry sprinkler heads as required by NFPA 101 Life Safety Code. | F |
Report Facts
Resident census: 199
Total capacity: 220
Deficiencies cited: 11
Weight loss percentage: 11.4
Dates of survey: Survey conducted from 8/25/2025 through 8/28/2025; Life Safety Code survey on 8/26/2025
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 30, 2024
Visit Reason
An off-site desk audit was conducted to verify correction of all previous deficiencies cited on July 26, 2024.
Findings
Based on an acceptable plan of correction and supporting documentation, all previous deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 197
Capacity: 220
Deficiencies: 7
Jul 26, 2024
Visit Reason
A Recertification Survey and complaint investigation survey were conducted at Berkshire Place Nursing Home from 7/23/2024 through 7/26/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were cited related to failure to develop and implement comprehensive person-centered care plans, failure to meet professional standards of care, failure to provide necessary services for dependent residents, failure to provide respiratory care consistent with professional standards, failure to ensure residents are free of significant medication errors, and failure to maintain accurate and complete medical records. Life Safety Code deficiencies were also identified related to fire drills.
Complaint Details
The visit included a complaint investigation survey with ACTS Reference Numbers 96729 and 96829. Deficiencies were cited as a result of this complaint investigation.
Severity Breakdown
Level 3: 1
Level 4: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to develop and implement a comprehensive person-centered care plan for 1 of 5 residents relative to smoking, Resident ID #186. | — |
| Facility failed to ensure services provided met professional standards for 3 residents reviewed for lab tests, daily weights, and psychiatric consults. | — |
| Facility failed to provide necessary services to a resident unable to carry out activities of daily living related to scheduled showers, Resident ID #111. | — |
| Facility failed to provide respiratory care consistent with professional standards for 1 of 2 residents reviewed for respiratory care, Resident ID #159. | — |
| Facility failed to ensure residents were free of significant medication errors for 4 of 9 residents reviewed for medication administration, Resident IDs #111, 136, 162, and 186. | Level 3 |
| Facility failed to maintain accurate, complete, and accessible medical records for 1 resident, Resident ID #241. | — |
| Life Safety Code deficiency: Facility failed to provide evidence that fire drills were conducted quarterly on all shifts as required. | Level 4 |
Report Facts
Capacity: 220
Census: 197
Residents reviewed for medication errors: 9
Residents with medication errors: 4
Residents reviewed for respiratory care: 2
Residents reviewed for showers: 4
Residents reviewed for psychiatric evaluations: 4
Fire drills documented: 3
Inspection Report
Follow-Up
Deficiencies: 0
Jul 10, 2023
Visit Reason
A follow-up revisit to a previous recertification and complaint investigation survey was conducted at the facility to verify correction of prior deficiencies.
Findings
All previous deficiencies were corrected and no new deficiencies were identified during the follow-up visit.
Complaint Details
The visit was complaint-related as it was a follow-up to a complaint investigation; all previous deficiencies were corrected.
Inspection Report
Complaint Investigation
Deficiencies: 9
Jun 8, 2023
Visit Reason
A Recertification and Complaint Investigation Survey was conducted at Berkshire Place from 6/5/2023 through 6/8/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure, emergency preparedness, and a Compliance Vaccination Survey.
Findings
Deficiencies were identified related to Resident Rights/Exercise of Rights, Services Provided Meeting Professional Standards, Skin Integrity, Nutrition/Hydration Status, Pain Management, Drug Regimen Review, Food Procurement and Safety, Resident-Identifiable Information, and Life Safety Code compliance. The facility failed to treat residents with dignity and respect, ensure proper medication administration, maintain adequate nutrition and hydration, and comply with safety and documentation standards.
Complaint Details
The visit was triggered by a complaint investigation as part of a Recertification and Complaint Investigation Survey. Specific substantiation status is not stated.
Deficiencies (9)
| Description |
|---|
| Facility failed to treat residents with respect and dignity in an environment that promotes maintenance of quality of life for 1 of 16 residents observed requiring total assistance for hygiene and 2 of 10 residents requiring total assistance for feeding. |
| Facility failed to ensure services provided met professional standards of quality for 1 of 6 residents reviewed related to antipsychotic medication orders and monitoring. |
| Facility failed to provide necessary treatment and services to prevent new pressure ulcers for 2 of 10 residents reviewed. |
| Facility failed to ensure residents maintained acceptable nutritional status for 2 of 14 residents reviewed. |
| Facility failed to ensure pain management was provided consistent with professional standards for 1 of 3 residents reviewed. |
| Facility failed to conduct monthly drug regimen reviews and report irregularities for 1 of 8 residents reviewed. |
| Facility failed to ensure food safety standards were met including proper dishwashing and hand hygiene. |
| Facility failed to maintain medical records accurately and protect resident-identifiable information for 3 residents reviewed. |
| Facility failed to maintain means of egress free of obstructions and comply with fire safety code requirements. |
Report Facts
Residents observed: 16
Residents reviewed: 6
Residents reviewed: 10
Residents reviewed: 14
Residents reviewed: 3
Residents reviewed: 8
Residents reviewed: 3
Residents affected: 156
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 3, 2022
Visit Reason
A Complaint/Incident Investigation Survey was conducted to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
No deficiencies were cited as a result of this survey.
Complaint Details
The survey was conducted as a complaint/incident investigation with ACTS Reference Numbers 86986, 86950, and 86947. No deficiencies were found.
Inspection Report
Follow-Up
Deficiencies: 0
Jun 16, 2022
Visit Reason
An off-site desk audit was conducted on June 16, 2022 for all previous deficiencies cited on May 13, 2022.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 191
Capacity: 220
Deficiencies: 10
May 13, 2022
Visit Reason
A Recertification and Complaint Investigation Survey was conducted from 05/09/2022 through 05/13/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness survey and a Compliance Vaccination Survey.
Findings
The facility was found deficient in multiple areas including comprehensive resident assessments, professional standards of care, nutrition and hydration maintenance, parenteral fluids administration, respiratory care, medication error rates, drug regimen management, labeling and storage of drugs, food safety, and infection prevention and control. No residents were harmed by the alleged deficient practices.
Complaint Details
The survey included a complaint investigation as indicated by ACTS Reference numbers 84654, 84617, 84903, and 84961. No residents were harmed by the alleged deficient practices.
Deficiencies (10)
| Description |
|---|
| Failure to conduct comprehensive assessments of residents' functional capacity and needs. |
| Failure to meet professional standards of care for new resident admissions and dietary physician orders. |
| Failure to maintain acceptable nutritional status and hydration for residents. |
| Failure to administer parenteral fluids consistent with professional standards and physician orders. |
| Failure to provide respiratory care including tracheostomy and suctioning consistent with professional standards. |
| Medication error rate exceeded 5 percent, with errors involving multiple residents. |
| Failure to ensure drug regimen free from unnecessary drugs and excessive doses. |
| Failure to label and store drugs and biologicals according to accepted professional principles. |
| Failure to maintain food safety standards including cleanliness and temperature monitoring. |
| Failure to establish and maintain an infection prevention and control program. |
Report Facts
Census: 191
Total Capacity: 220
Medication error rate: 15.38
Medication errors: 6
Residents reviewed for dietary physician orders: 35
Residents reviewed for restraints: 6
Residents reviewed for weight loss: 3
Medication storage rooms reviewed: 3
Medication carts observed: 7
Residents' rooms observed: 2
Medication packets observed: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lindsay Bouchard | Administrator | Signed the Plan of Correction on 5/26/2022. |
| Staff Nurse A | Acknowledged dressing dates and medication record issues during observations. | |
| Staff Nurse B | Acknowledged resident medication observations. | |
| Staff Nurse C | Observed medication administration errors and acknowledged observations. | |
| Staff Nurse F | Observed medication storage and administration. | |
| Staff Nurse G | Observed medication administration. | |
| Staff Nurse H | Observed medication storage and expiration dates. | |
| Director of Nursing Services | Interviewed regarding resident care plans and medication administration. | |
| Director of Nursing Services | Interviewed on 5/12/2022 about PICC line dressing changes and oxygen orders. | |
| Registered Dietician | Interviewed regarding weight monitoring and dietary plans. | |
| Staff J Cook | Observed not wearing beard covering during meal preparation. |
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