Berkshire Place
Berkshire Place in Providence, RI — inspection on April 30, 2026.
Found 2 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
During a surveyor interview on 4/30/2026 at 4:08 PM with the Administrator, she acknowledged that Resident ID #2 was discharged into police custody on 4/27/2026 secondary to admitted ly striking Resident ID #1 with his/her cane that resulted in injury.
Record review of a [police department] Incident Report dated 4/27/2026 revealed Resident ID #1 wanted to press charges after stating s/he was struck with a walking cane.
Resident ID #2 admitted to striking Resident ID #1 with his/her cane.
The report further revealed Resident ID #2 was subsequently arrested on one count of felony assault with a dangerous weapon.The facility's failure to assess, monitor, and implement effective interventions to address Resident ID #2's known history of escalating aggressive behaviors, including failure to update the care plan and fully implement psychiatric recommendations, resulted in a resident-to-resident altercation causing injury to Resident ID #1, and demonstrates the facility did not ensure a safe environment free from abuse.Cross reference F-F740
415119 04/30/2026
Berkshire Place 455 Douglas Avenue Providence, RI 02908
2/21/2026, and 4/27/2026.Additional record review failed to reveal interventions to mitigate the risk of Resident ID #2's physically aggressive behaviors toward other residents, or interventions for staff to implement to ensure the safety of other residents residing in the facility, following the resident-to-resident incident on 2/21/2026 and the documented throwing of objects on 3/9/2026 and 4/10/2026.During a surveyor interview on 4/30/2026 with the Registered Nurse Practitioner (RNP), Staff A, at 1:48 PM, she stated it would be her expectation that the order for trazodone would have included agitation and anxiety as indications for use.During a surveyor interview on 4/30/2026 at approximately 3:50 PM with the Director of Nursing Services (DNS), she stated it would be her expectation that the trazodone order would have included agitation and anxiety as indications for use.
Additionally, she was unable to provide evidence that Resident ID #2's care plan was updated to include interventions to mitigate the risk of his/her physically aggressive behaviors, as documented on 2/21/2026, 3/9/2026, and 4/10/2026.The facility's failure to fully implement the psychiatric recommendation for trazodone and to update the care plan with effective behavioral interventions following Resident ID #2's known and escalating pattern of aggressive behaviors resulted in a resident-to-resident altercation on 4/27/2026 that caused physical injury to Resident ID #1 and demonstrated the facility's failure to provide adequate behavioral health services to support Resident ID #2's highest practicable mental and psychosocial well-being, while simultaneously placing other residents at risk of harm.
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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.