Berkshire Place

In the surveyor’s words

From the most serious findings on record at Berkshire Place, in the surveyor’s own words.

• Immediate jeopardy, isolatedF698Apr 25, 2023

  Based on record review and staff interview it has been determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice relative to having policies and procedures for dialysis care for 3 of 3 residents, not providing appropriate transportation for 1 of 3 residents, observation and assessment of access site for 2 of 3 residents, not monitoring fluid intake and for staff failing to report a resident missing dialysis appointments for 1 of 3 residents reviewed, Resident ID #'s 1, 2 and 3. Findings are as follows: 1. […]

• Immediate jeopardy, isolatedF656Apr 10, 2023

  Based on record review and staff interview, it has been determined that the facility failed to implement care plan interventions to monitor a resident with a known history of wandering and exit seeking, which resulted in the resident leaving the building unsupervised, putting the resident at risk for serious injury or death., for 1 of 1 residents reviewed who successfully eloped from the facility, Resident ID #1. Findings are as follows: Record review of a facility policy titled, POLICY AND PROCEDURE Elopement Assessments states in part, POLICY: It is the policy of this facility to maintain a safe and secure environment for all of our residents. In order to achieve this; residents who are at risk for wandering/elopement need to be identified and a care plan developed to eliminate the risk. […]

• Immediate jeopardy, isolatedF689Apr 10, 2023

  Based on record review, surveyor observation, and staff interview, it has been determined that the facility failed to ensure that residents identified as an elopement risk received adequate supervision to prevent elopement from the facility for 1 of 1 residents reviewed for actual elopement, Resident ID #1. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 4/3/2023 states, .resident was attempting to elope at 6:30 PM .At 8:45 PM staff was unable to find resident .search was initiated .around 10:30 PM the temperatures were around 37 degrees and Administrator and DNS [Director of Nursing Services] decided to contact the [name redacted] Police .Between 1 AM and 2AM received a call from [name redacted] police .they have… […]

• Actual harm, patternF688Sep 4, 2025

  Based 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. […]

• Actual harm, patternF841Apr 25, 2023

  Based on record review and staff interview, it has been determined that the Medical Director failed to implement a resident care policy to coordinate care for residents who require dialysis (a life sustaining therapy that can replace the work of non-functioning kidneys) for 3 of 3 residents reviewed, Resident ID #s 1, 2, and 3. Findings are as follows: Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities revised 2/3/2023 states in part, Nursing facilities .must develop dialysis specific policies/procedures, based upon current standards of practice. […]