Inspection Reports for
Berkshire Place Nursing and Rehabilitation Center

The facility was found deficient in multiple areas including medication administration, pressure ulcer care, range of motion maintenance, nutritional status, laboratory services, food safety, and quality assurance processes. Several residents experienced harm or potential harm due to failures in care and oversight.

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.

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.

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.

The investigation was triggered by complaints submitted to the Rhode Island Department of Health on 5/19/2025 alleging failure to report abuse and improper medication storage and administration. The abuse allegation involved Resident ID #1 threatening another resident on 3/13/2025. The medication complaint involved improper storage and labeling of medications on medication carts.

The facility failed to report an alleged abuse incident involving a resident threatening another resident in a timely manner to the state agency. Additionally, the facility failed to properly store and label medications on multiple medication carts, including opened medications not dated and medications not refrigerated as required.

The complaint was substantiated. It was confirmed that the resident eloped on 2/3/2025, and the facility failed to perform required assessments and care planning post-elopement. Staff interviews corroborated the findings.

The facility failed to ensure adequate supervision to prevent a resident's elopement and did not perform required elopement assessments or develop a care plan with interventions after the incident. Staff interviews confirmed lack of documentation for AMA discharge and elopement evaluation.

The complaint alleged that Resident ID #1 was not permitted to return to the facility after hospitalization and was not given a 30-day notice as required. The complaint was submitted to the Rhode Island Department of Health on 2025-01-15.

The facility failed to notify the resident and the resident's representative in writing about the transfer or discharge and the reasons for the move. The facility also failed to provide written notice regarding the bed-hold policy and did not allow the resident to return to the facility after hospitalization.

The complaint alleged that hot food items were served cold and that staff members serving food did not wear hairnets. The complaint was submitted to the Rhode Island Department of Health on 11/4/2024.

The facility failed to provide food and drinks at a safe and appetizing temperature for multiple residents, with food temperatures below the facility's policy standards. Additionally, staff were observed not wearing hair restraints in the kitchen, violating food safety standards.

The complaint investigation was substantiated based on multiple resident interviews, staff interviews, and a police report. Resident ID #1 was arrested for second degree sexual assault after being witnessed touching Resident ID #2 inappropriately.

The facility failed to protect a resident's right to be free from abuse involving sexual contact between residents. Evidence included resident interviews, staff reports, and a police report resulting in an arrest for second degree sexual assault.

The facility failed to develop and implement comprehensive care plans, follow physician orders, provide scheduled showers, document respiratory care properly, prevent medication errors, and maintain accurate medical records for several residents. Multiple residents were affected by these deficiencies, with minimal harm or potential for harm noted.

The facility failed to follow physician's orders for laboratory tests, psychiatric consults, and daily weights for certain residents. Additionally, inaccurate documentation of care and failure to maintain accurate medical records were identified.

The visit included a complaint investigation survey with ACTS Reference Numbers 96729 and 96829. Deficiencies were cited as a result of this complaint investigation.

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.

The complaint investigation was substantiated based on observations, record reviews, and staff interviews confirming the use of physical restraints on Resident ID #1 without medical justification.

The facility failed to ensure that residents are free from physical restraints unless medically necessary. Evidence showed that Resident ID #1 was found with bed sheets tied to the bedframe and wrapped around the resident's feet, constituting improper restraint use.

The complaint was substantiated based on record reviews and staff interviews revealing multiple medication errors for Resident ID #1, including administration of incorrect medication and undocumented doses. Similar issues were found for Residents #3 and #4.

The facility failed to ensure residents were free from significant medication errors for 3 of 4 residents reviewed who were receiving pain medication. Multiple medication administration errors and discrepancies were identified involving Residents #1, #3, and #4, including incorrect dosages, undocumented administration, and possible signature forgery.

The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to meet professional standards of care, inadequate pressure ulcer prevention, nutritional deficiencies, pain management issues, medication regimen irregularities, failure to provide adaptive eating utensils, improper food service sanitation, and inaccurate medical record documentation.

The facility was found deficient in multiple areas including resident dignity and respect, medication management, pressure ulcer care, nutritional status, pain management, medication regimen review, psychotropic medication use, provision of adaptive eating equipment, food service safety, and medical record accuracy.

The visit was triggered by a complaint investigation as part of a Recertification and Complaint Investigation Survey. Specific substantiation status is not stated.

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.

The complaint investigation was triggered by a community complaint dated 4/17/2023 alleging that Resident ID #1 missed two dialysis treatments due to the facility's failure to secure appropriate transportation, resulting in hospital admission.

The facility failed to ensure professional standards of quality in dialysis care for residents, including failure to follow physician orders for daily weights, lack of dialysis-specific policies, inadequate transportation arrangements causing missed dialysis treatments, failure to monitor fluid intake and access sites, and failure to provide pharmaceutical services as ordered. The Medical Director also failed to implement policies to coordinate dialysis care.

The facility failed to develop and implement comprehensive, measurable care plans for residents, ensure appropriate monitoring and treatment of diabetes, maintain residents' nutritional status, and provide pharmaceutical services to meet residents' needs. Significant deficiencies were found in medication administration, monitoring of blood sugar and weight, and communication with healthcare providers.

The complaint investigation substantiated that the facility failed to implement care plan interventions and adequate supervision for a resident at risk of elopement. The resident eloped on 4/2/2023, was found approximately 2.6 miles away with serious injuries, and was hospitalized. The facility delayed police notification by about two hours after the resident was identified missing.

The facility failed to implement a care plan and adequate supervision for a resident identified as an elopement risk. The resident successfully eloped on 4/2/2023, resulting in a hip fracture and brain bleed. The facility delayed contacting police and did not have appropriate interventions in place despite documented risk assessments and exit-seeking behaviors.

The complaint investigation found that the orthopedic appointment was not scheduled as ordered. The Licensed Practical Nurse Unit Manager could not provide evidence of scheduling or offering the appointment. The Director of Nursing acknowledged the failure to schedule the appointment since November 2022. An appointment was scheduled on the day of the survey after the issue was raised.

The facility failed to schedule an orthopedic consultation for a resident as ordered by the physician. Staff documented the order as completed, but no evidence of scheduling or offering the appointment was found until the surveyor brought the issue to the facility's attention.

The complaint investigation found that the knee immobilizer was used without a physician's order. The Nurse Practitioner confirmed the hospital recommended continuous use until orthopedic follow-up, but no order was documented in the facility records. The resident missed two orthopedic appointments and the Nurse Practitioner indicated the immobilizer was not needed and posed risks.

The facility failed to meet professional standards of quality by using a knee immobilizer on Resident ID #3 without a documented physician's order. The resident was non-weightbearing on the right lower extremity following a fractured femur, but no formal order for the immobilizer or non-weightbearing status was found in the medical record.

The complaint alleged that a resident had an unwitnessed fall at 1:00 AM and EMS was not contacted until 8:45 AM. The investigation confirmed delayed notification to the physician and inadequate post-fall assessment by staff.

The facility failed to immediately consult the resident's physician or notify the resident's representative after a fall resulting in a significant change in the resident's physical and mental status. Staff did not properly assess the resident post-fall, delayed contacting the doctor, and inaccurately documented oxygen saturation levels.

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.

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.