Cycle 1
Health 2025-07-18 · Fire 2025-07-18
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Pascoag, RI
Bayberry Commons
2-star overall rating with 3-star inspections with $51,948 in total fines with 5 recent health deficiencies
181 Davis Drive, Pascoag, RI
(401) 568-0600
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
96
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1985-04-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.57
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.46
Nurse aide staffing · state 2.46 · national 2.35
Total nurse hours
3.57
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.11
RN + LPN hours · state 1.25 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.30 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
4.15
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 38% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,375
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9857
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 22.79% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
1.78
Performance 7.30% · Measure score 1.78 · Achievement 1.78 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
7.52
Performance 32.93% · Measure score 7.52 · Achievement 7.52 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.67
Baseline 4.11 hours · Performance 3.84 hours · Measure score 2.67 · Achievement 2.67 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.26% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 65 · Observed rate 15.38% · Lower 95% interval 7.79% |
| Discharge to community | 41.91% |
50.57%
8.7 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 32.76% · Lower 95% interval 31.24% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 93.33% |
95.27%
1.9 pts worse
|
Numerator 28 · Denominator 30 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 30 |
| Discharge self-care score | 40.91% |
53.69%
12.8 pts worse
|
Numerator 9 · Denominator 22 |
| Discharge mobility score | 54.55% |
50.94%
3.6 pts better
|
Numerator 12 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 10% |
2.29%
7.7 pts worse
|
Numerator 3 · Denominator 30 · Adjusted rate 9.02% |
| Healthcare-associated infections requiring hospitalization | 7.3% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 6.9% · Lower 95% interval 3.77% |
| Staff COVID-19 vaccination coverage | 4.65% |
8.2%
3.5 pts worse
|
Numerator 8 · Denominator 172 |
| Staff flu vaccination coverage | 16.67% |
42%
25.3 pts worse
|
Numerator 34 · Denominator 204 |
| Discharge function score | 59.09% |
56.45%
2.6 pts better
|
Numerator 13 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.5
0.3 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.3 |
1.7
1.6 pts worse
|
1.8
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 2.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.5% |
93.2%
7.7 pts worse
|
93.4%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 89.6% · Q2 87.5% · Q3 82.4% · Q4 82.0% · 4Q avg 85.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.9% |
95.3%
5.4 pts worse
|
95.5%
5.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.4% |
3.6%
4.8 pts worse
|
3.3%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 10.2% · Q3 10.6% · Q4 9.0% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.1% |
14.6%
10.5 pts better
|
11.4%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.3% · Q3 2.7% · Q4 9.9% · 4Q avg 4.1% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
5.3%
2 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 7.7% · Q3 5.2% · Q4 9.0% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.5% |
16.4%
7.1 pts worse
|
19.6%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 24.4% · Q3 25.6% · Q4 20.3% · 4Q avg 23.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 35.1% |
23.6%
11.5 pts worse
|
16.7%
18.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.2% · Q2 27.3% · Q3 37.5% · Q4 40.0% · 4Q avg 35.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.5% |
17.0%
0.5 pts worse
|
16.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.6% · Q2 24.1% · Q3 14.7% · Q4 14.2% · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.7% |
18.4%
11.3 pts worse
|
14.9%
14.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.5% · Q2 32.4% · Q3 32.9% · Q4 32.9% · 4Q avg 29.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.6% |
2.2%
3.4 pts worse
|
1.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 8.0% · Q3 4.8% · Q4 3.4% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.7% |
22.3%
1.4 pts worse
|
19.8%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 24.0% · Q3 17.3% · Q4 32.2% · 4Q avg 23.7% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
4.7%
0.6 pts worse
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 5.2% · Q3 2.7% · Q4 6.5% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 50.4% |
77.2%
26.8 pts worse
|
81.7%
31.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 51.1% · Q2 39.7% · Q3 54.4% · Q4 55.6% · 4Q avg 50.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.7% |
15.8%
8.9 pts worse
|
12.0%
12.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.7% · Observed 25.9% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.9%
0.2 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.8% · Q4 3.3% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 64.4% |
78.2%
13.8 pts worse
|
79.7%
15.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 64.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.7% |
25.1%
0.4 pts better
|
23.9%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.7% · Observed 25.9% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-11 · Fire 2024-07-11
12 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-06-22 · Fire 2023-06-22
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-18
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-08-17
E · Potential for more than minimal harm
2025-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-17
D · Potential for more than minimal harm
2025-07-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-08-17
D · Potential for more than minimal harm
2025-07-18
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-08-17
D · Potential for more than minimal harm
2025-07-03
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-08-02
G · Actual harm
2025-02-20
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-22
D · Potential for more than minimal harm
2025-02-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-22
J · Immediate jeopardy
2024-12-19
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-01-07
D · Potential for more than minimal harm
2024-08-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-08-15
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-09-04
G · Actual harm
2024-08-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-07-11
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-08-10
E · Potential for more than minimal harm
2024-07-11
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-08-10
E · Potential for more than minimal harm
2024-07-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-10
E · Potential for more than minimal harm
2024-07-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-10
D · Potential for more than minimal harm
2024-07-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-10
D · Potential for more than minimal harm
2024-07-11
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-08-10
D · Potential for more than minimal harm
2023-06-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-22
D · Potential for more than minimal harm
2023-06-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-07-22
D · Potential for more than minimal harm
2023-06-22
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-07-22
Penalties and ownership
What sits behind the stars
$19,136
2025-02-20
Fine
Fine · fine $19,136
Fine
$24,794
2024-12-19
Fine
Fine · fine $24,794
Fine
$8,018
2024-07-11
Fine
Fine · fine $8,018
Fine
Ownership
David Ryan Family Associates LLC
5% Or Greater Direct Ownership Interest · Organization
Altongy-Boudjouk, Jennifer
W-2 Managing Employee · Individual
Arnold, Kelly
Operational/Managerial Control · Individual
Carragher, Terry
Corporate Officer · Individual
David Ryan Family Associates LLC
Operational/Managerial Control · Organization
Health Concepts Ltd
Operational/Managerial Control · Organization
Keene, Debra
W-2 Managing Employee · Individual
Ryan, David
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Crystal Lake Rehabilitation and Care Center
Pascoag, RI
1-star overall rating with 1-star inspections with $306,656 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Overlook Nursing and Rehabilitation Center
Pascoag, RI
3-star overall rating with 3-star inspections with $10,358 in total fines with 14 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Greenville Operations RI LLC DBA Greenville Skille
Greenville, RI
1-star overall rating with 1-star inspections with $259,161 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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