Berkshire Place

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure Resident ID #1's right to be free from abuse by failing to assess, monitor, and implement effective interventions to address Resident ID #2's known and escalating history of physically aggressive behaviors including failure to update the care plan following documented resident-to-resident incidents and failure to fully implement psychiatric recommendations resulting in a resident-to-resident altercation on 4/27/2026 in which Resident ID #2 struck Resident ID #1 on the left eyebrow with a cane, causing a laceration requiring wound closure with steri-strips and ongoing wound treatment. [...]

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that a resident received adequate behavioral health services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, for 1 of 2 residents reviewed, Resident ID #2. Specifically, the facility failed to implement the full psychiatric recommendation for the administration of trazodone, including agitation and anxiety as indications.

Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed with a foley catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag), Resident ID #1, and for 2 of 2 residents with a suprapubic catheter (SP tube, a medical device that drains urine from the bladder through a small incision in the abdomen) Resident ID #s 2 and 3.

Inspectors wroteBased on surveyor observation, record review, family member, and staff interview, it has been determined that the facility failed to ensure that a resident who was admitted to the facility without a limited range of motion does not experience a reduction in range of motion for 1 of 2 residents observed with contractures (the shortening of muscles, tendons, skin, and nearby soft tissues that cause the joints to become very stiff, which prevent normal movement), Resident ID #99.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight, for 1 of 9 residents reviewed for weight loss, Resident ID #4.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed in accordance with professional standards for food service safety, relative to the main kitchen and 4 of 4 kitchenettes observed.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to maintain documentation and demonstrate evidence of its ongoing Quality Assurance and Performance Improvement (QAPI) program relative to a performance improvement project (PIP) involving significant weight loss.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to following the parameters for a physician's order for Metoprolol Succinate Extended Release (a medication prescribed to treat various heart conditions), for one of one resident reviewed, Resident ID #125.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 2 of 7 residents reviewed with pressure ulcers (a localized injury to the skin and/or underlying skin usually over a boney prominence), Resident ID #s 4 and 99.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to obtain laboratory services to meet the needs of its residents for 1 of 4 residents reviewed, Resident ID #2.

Inspectors wroteBased on surveyor observation and staff interview, it has been determined that the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services relative to the testing of the water temperature of the main dishwashing machine to ensure proper sanitization.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or, no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the local state agency (Rhode Island Department of Health, RIDOH), in accordance with State law, for 1 of 2 residents reviewed for allegations of abuse, Resident ID #1.

Inspectors wroteBased on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 2 of 4 medication carts observed.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure a resident receives adequate supervision to prevent accidents for 1 of 1 resident reviewed who successfully eloped from the facility, Resident ID #2.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to notify the resident and the resident's representative(s) of a transfer or discharge and the reasons for the move in writing and in a language and manner they understand for 1 of 1 resident who was transferred to the hospital and discharged from the facility, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide evidence that written notification was provided to the resident or resident representative(s) regarding a bed hold. Additionally, at the time of transfer the facility failed to provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy for 1 of 1 resident who was transferred to the hospital, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that after a resident was transferred to the hospital, the facility failed to allow the resident to return to facility where s/he resided for several years for 1 of 1 resident reviewed who was transferred to the hospital, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to prepare, store, and distribute food according to professional standards of food service safety, relative to 1 of 1 meal pass observed, and 1 of 2 observations of the main kitchen relative to use of hair restraints.

Inspectors wroteBased on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to provide food and drinks that are palatable, attractive, and at an appetizing temperature for 4 of 5 residents reviewed, Resident ID #s 2, 3, 4, and 5.

Inspectors wroteBased on record review, staff, and resident interview, it has been determined that the facility failed to protect a resident's right to be free from abuse for 1 of 2 residents reviewed, Resident ID #2.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 4 of 9 residents reviewed for medication administration, Resident ID #s 111, 136, 162, and 186.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 5 residents reviewed relative to smoking, Resident ID #186.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice relative to following physician's orders for 1 of 3 residents reviewed for obtaining laboratory results, Resident ID #162, and 1 of 1 resident reviewed for obtaining a psychiatric consult and daily weights, Resident ID #241.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary services to a resident who is unable to carry out activities of daily living relative to scheduled showers for 1 of 1 resident reviewed who had concerns regarding shower provision, Resident ID #111.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 residents reviewed for respiratory care, Resident ID #159.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 1 resident reviewed for showers and 1 of 4 residents reviewed for non-pressure wound treatments, Resident ID #111, and 1 of 1 resident reviewed for psychiatric evaluations, Resident ID #241.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure residents have the right to be free from any physical restraint not required to treat the resident's medical symptoms for 1 of 1 resident reviewed, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight for 2 of 14 residents reviewed for nutrition, Resident ID#s 115 and 93.

Inspectors wroteBased on record review, resident and staff interview, it has been determined that the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 resident reviewed for pain management, Resident ID #159.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to monitor and ensure that heat sanitization was achieved for a high temperature dish machine and that staff utilize proper hand hygiene practices in accordance with professional standards for food service safety relative to the main kitchen.

Inspectors wroteBased on surveyor observation, record review, and resident and staff interview, it has been determined that the facility failed to treat each resident with respect and dignity in an environment that promotes maintenance of his or her quality of life for 1 of 16 residents observed who require total assistance from staff for hygiene, Resident ID # 95 and 2 of 10 residents observed who require total assistance from staff for feeding, Resident ID #s 115 and 173.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality for 1 of 6 residents reviewed relative to a physician's order for as needed antipsychotic medication, Resident ID #125 and 1 of 4 residents reviewed for limited range of motion, Resident ID #173.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary psychotropic drugs who have as needed psychotropic medication orders extending beyond 14 days, for 1 of 8 residents reviewed for unnecessary medication, Resident ID #97.

Inspectors wroteBased on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to maintain medical records in accordance with professional standards and practices for 1 of 3 residents reviewed for offloading booties, Resident ID #3 and 1 of 3 residents reviewed for compression stockings, Resident #97.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to prevent new pressure ulcers from developing for 2 of 10 residents reviewed, Resident ID #s 3 and 173.

Inspectors wroteBased on record review and staff interview, it has been determined that the pharmacist failed to report any irregularities to the attending physician, the facility's Medical Director, and the Director of Nursing Services (DNS) for 1 of 8 residents reviewed for monthly drug regime reviews, Resident ID #97.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide special adaptive eating equipment for residents who need them, for 1 of 4 residents reviewed who require specialized adaptive eating equipment, Resident ID #115.