Roberts Health Centre Inc
Roberts Health Centre Inc in North Kingstown, RI — inspection on May 26, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
properly.3/4/2025- chair alarm to recliner.
This order was discontinued on 5/14/2026.6/16/2024- bed
evidence that alarms were utilized for the resident.3f.
Record review revealed Resident ID #38 was
review revealed an order dated 11/10/2025 to check that the bed alarm is functioning.
Record review of an Annual MDS assessment dated [DATE] failed to reveal evidence that alarms were utilized for the resident.During a surveyor interview on 5/20/2026 at approximately 1:45 PM with MDS Coordinator, Staff D, she was unable to provide evidence that the admission assessment for Resident ID #50 was completed within 14 days, as required.
Additionally, she revealed that the MDS Assessments should include oxygen if oxygen was administered to the resident during the lookback period; however, she was unable to provide evidence that oxygen usage was documented on the MDS Assessments for Resident IDs #1 and #2.
Lastly, she revealed that the MDS assessments should include alarms that are utilized for the residents during the lookback period, but was unable to provide evidence that the alarm usage was documented on the MDS Assessments for Resident ID #s 7, 13, 30, 36, 37 and 38.
needed assistance. A staff member entered the room at 10:59 AM to assist the resident.
The resident
that she would notify the nurse.
Record review of a Weekly Skin/Body Assessment dated 5/19/2026,
observation of the reddened toes, failed to reveal any skin impairments to the resident's feet.
Further review revealed this assessment was completed by Registered Nurse (RN), Staff E.During a surveyor interview on 5/21/2026 at 9:30 AM with Resident ID #45, four days after the initial interview and observation, the resident revealed that his/her right foot is still painful and the facility had not done anything for it.During a surveyor interview on 5/21/2026 at 9:32 AM with RN, Staff E, she revealed that she was aware that the resident previously had issues with his/her toes, had been seen by podiatry, his/her family member brought him/her new shoes, and that a treatment was in place to apply skin prep daily.
Additionally, she stated that the resident's toes were not red at the time of the skin assessment that she completed on 5/19/2026, in the presence of Nursing Assistant (NA), Staff F.During a surveyor interview on 5/21/2026 at 9:56 AM with NA, Staff F, she revealed that she assisted Resident ID #45 with a shower on 5/19/2026 at which time she observed the resident's toes to be reddened and painful while she was washing his/her feet.
Staff F revealed that she informed the nurse and the nurse applied skin prep to the resident's toes following the nurse's skin check.
Additionally, she revealed that she provides care for the resident weekly and that his/her toes have been reddened for a while.
Record review failed to reveal evidence that the provider was notified of the painful, reddened toes prior to the surveyor bringing the concern to the facility's attention on 5/21/2026.
Record review of a progress note dated 5/21/2026 at 10:36 AM revealed the following:- the resident was noted to have redness to his/her right foot in the outer 5th toe area, blanchable redness to the 3rd toe with a pinpoint scabbed area, and a white, dry, irritated area between the 4th and 5th toes.- the top of the resident's left foot 2nd toe was pink and blanchable- Nurse Practitioner (NP), Staff G was notified and gave new orders for a podiatry consult and treatments- orthopedic shoes removed and old shoes with cut out toe area applied- the resident complained of pain to his/her feet at night
Record review revealed the following new orders were received on 5/21/2026, following the NP notification:- Apply Iodosorb (a wound gel) to the 3rd toe pinpoint area on the right foot and cover with a bandaid daily- Apply 2x2 gauze between the 4th and 5th toes on the right foot daily- Apply shoes with cutout in toes and remove at bedtimeDuring surveyor interviews on 5/21/2026 at 10:00 AM and at 12:28 PM with the Director of Nursing Services (DNS), she revealed that she would not expect a nurse to document redness to a resident's skin if the redness was chronic and to only document if there was a change or if pain was observed.
She further revealed that she would expect the provider to be notified if there was a change in the resident's skin or if pain was assessed.Record review of a progress note received by email from the DNS, dated 5/22/2026 and authored by the NP, Staff G, revealed the resident was noted with an open area/pressure wound on his/her right 3rd toe, to continue with the wound dressing as ordered, and to follow up with the inhouse wound specialist.
Further review revealed the resident was to avoid any pressure on the right foot and to begin Ultram 25 milligrams (a medication prescribed to treat pain) daily as needed for 14 days for pain management.The surveyor attempted to contact the resident's Nurse Practitioner (NP), Staff G, on 5/21/2026 at 12:18 PM and on 5/22/2026 at 1:34 PM. A message was left; however, no return phone call was received.
Due to the facility's failure to accurately assess the resident's skin condition, recognize changes in skin integrity and complaints of pain, and timely notify the provider, the resident did not receive appropriate treatment and interventions in a timely manner, resulting in worsening skin impairment and further deterioration of the toes.
415104 05/26/2026
Roberts Health Centre Inc 25 Roberts Way North Kingstown, RI 02852
culture results, received on 5/23/2026, indicated that the resident's ulcer was infected with MRSA.
ulcer, the resident did not receive timely assessment, treatment, or implementation of appropriate
management for approximately 21 days, during which time the wound progressed without appropriate oversight, resulting in the resident experiencing pain, infection, and avoidable clinical decline.
415104 05/26/2026
Roberts Health Centre Inc 25 Roberts Way North Kingstown, RI 02852
serve food in accordance with professional standards.
food in accordance with professional standards for food service safety relative to the main kitchen
2022 Edition, Section 3-501.17 states in part, .READY -TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees Celsius or 41 degrees Fahrenheit or less for a maximum of 7 days.
The day of preparation shall be counted as Day 1 .Surveyor observation of the refrigerator during the initial tour of the kitchen on 5/18/2026 at 8:48 AM revealed the following:2 packages of Hormel natural choice roast beef with a use or freeze by date of 4/14/2026During a surveyor interview immediately following the above observations with Cook, Staff C, he acknowledged that the above items were expired and should have been discarded.2)
Record review of The Rhode Island Food Code 2022, Edition 4.601.11 reads in part, .(A) equipment food contact surfaces .shall be clean to sight .During a surveyor observation of the facility ice machine located in the second-floor kitchenette during the initial tour on 5/18/2026 at approximately 9:15 AM, revealed a pink substance located on the white shield on the inside of the machine where the ice is dispensed.During surveyor interviews with the Food Service Director on 5/18/2026 at 9:21 AM and 5/21/2026 at 8:30 AM, he acknowledged the pink substance inside of the ice machine and that it needed to be cleaned.
Additionally, he acknowledged that the roast beef was past its expiration date and should have been discarded.
415104 05/26/2026
Roberts Health Centre Inc 25 Roberts Way North Kingstown, RI 02852
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.