Roberts Health Centre: Wound Care Failure Causes Harm - RI
That was May 19, 2026. Four days later, the resident still had no treatment plan, no provider notification, and no relief from the pain. The toes were getting worse.
The sequence came to light only because a state surveyor happened to ask the resident about it first.
During an inspection visit on May 17, the resident told the surveyor his or her toes were red and painful. The surveyor observed the redness. The next day, a staff member entered the room at 10:59 AM after the resident called for help and told the resident the nurse would be notified. The weekly skin assessment completed by Registered Nurse Staff E on May 19 recorded nothing wrong with the resident's feet.
On May 21, the surveyor returned and asked the resident directly. The resident said the right foot was still painful and the facility had not done anything for it.
The surveyor then started asking staff what they knew.
RN Staff E said she was aware the resident had previously had toe problems, had seen a podiatrist, had received new shoes from a family member, and had a standing order for daily skin prep. She said the toes were not red when she did the skin check on May 19, with nursing assistant Staff F present in the room.
Staff F told a different story. She said she had washed the resident's feet during that same shower on May 19 and the toes were clearly red and painful. She told the nurse. The nurse then looked and applied skin prep. Staff F also said she provides care for this resident every week and that the toes had been reddened for a while.
The inspection record is direct about what the documentation showed: no evidence that any provider had been notified of the painful, reddened toes before the surveyor raised the concern on May 21.
Only after the surveyor intervened did anything happen. A progress note written that morning at 10:36 AM, once the surveyor had made clear the issue needed to be addressed, documented what the resident's feet actually looked like: redness to the outer fifth toe on the right foot, blanchable redness to the third toe with a pinpoint scabbed area, a white, dry, irritated area between the fourth and fifth toes, and a pink, blanchable area on top of the left foot's second toe. The resident also reported pain to the feet at night.
Nurse Practitioner Staff G was notified and issued new orders the same day: wound gel applied to the third toe and covered with a bandage daily, gauze placed between the fourth and fifth toes daily, and a shoe with a cutout in the toe area to be worn during the day and removed at bedtime. A podiatry consult was also ordered.
The following day, May 22, the nurse practitioner documented that the third toe now had an open area classified as a pressure wound. The resident was to avoid pressure on the right foot entirely and was started on a pain medication, tramadol, 25 milligrams daily as needed for 14 days.
What had been redness and pain on May 17 was an open wound requiring pain management by May 22.
The Director of Nursing Services, interviewed twice on May 21, offered an explanation for why none of this had been documented or escalated. She said she would not expect a nurse to document redness if it was chronic, only if there was a change or if pain was observed. She said she would expect a provider to be notified if there was a change in skin condition or if pain was assessed.
The inspection report does not reconcile that statement with what Staff F described: a resident who expressed pain while having her feet washed, whose toes were visibly red, whose nurse applied a topical product in response, and who then had a skin assessment completed the same day that recorded nothing abnormal.
The surveyor attempted to reach Nurse Practitioner Staff G on May 21 at 12:18 PM and again on May 22 at 1:34 PM. A message was left both times. No return call was received.
Inspectors classified the violation as causing actual harm to the resident. The finding states that because the facility failed to accurately assess the resident's skin, recognize changes in condition and complaints of pain, and notify the provider in time, the resident did not receive appropriate treatment, and the toes deteriorated further as a result.
The resident had told the surveyor about the pain on May 17. Eight days passed before a wound dressing was in place and a pain medication was prescribed. During that time, staff saw the problem, treated it informally, documented nothing, and told no one with authority to act.
The resident's right third toe, which a nursing assistant had noticed was red and sore during a routine shower, had by then broken open.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Roberts Health Centre Inc from 2026-05-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 14, 2026 · Our methodology
Roberts Health Centre Inc in North Kingstown, RI was cited for violations during a health inspection on May 26, 2026.
Four days later, the resident still had no treatment plan, no provider notification, and no relief from the pain.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.