Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elderwood Of Scallop Shell At Wakefield during CMS and state inspections, most recent first.
A resident with Parkinson’s disease and dysphagia had repeated coughing and choking episodes during meals and med pass, but staff did not notify the provider or implement interventions despite documentation and a therapy referral noting signs of aspiration. The resident was later found cyanotic and actively choking, requiring staff to remove food from the mouth and provide emergency assistance.
A resident with CHF and COPD did not receive all ordered extra Lasix doses and was not weighed daily as ordered. The MAR showed only 4 of 6 ordered Lasix doses were given, and the weight log did not show all required daily weights despite rapid weight gain, edema, and SOB on oxygen. Staff later observed worsening breathing with pursed lip breathing and an RR of 30, and the resident was sent to the hospital for evaluation.
A RN failed to respond appropriately to repeated choking episodes in a resident with Parkinson disease and dysphagia. Despite competency training and documented choking on food and meds, the RN did not notify the provider or implement interventions before the resident later had a severe choking event requiring emergency physical intervention, with signs of aspiration pneumonia and a diet change to pureed.
The facility failed to keep three residents’ drug regimens free from unnecessary medications. A resident with hypotension and HF received Metoprolol and Losartan outside ordered BP/HR hold parameters, another resident with HF and dementia received Metoprolol when BP was below the hold threshold, and a resident with chronic pain received more than the ordered max daily Acetaminophen dose when PRN Hydrocodone-Acetaminophen and Acetaminophen were combined. Staff acknowledged the documentation and dosing errors, and the DON stated staff should have followed the physician orders.
The facility failed to issue the required SNFABN when Medicare Part A coverage ended for three residents who remained in the facility after skilled coverage stopped. Record review showed no evidence that the residents or their representatives received the notice, and MDS nurses acknowledged the form was not provided. The Administrator and Interim DON were unable to produce evidence that the required notice had been given.
A resident with pressure ulcers did not receive daily dressing changes as ordered by the physician. The Treatment Administration Record showed missed dressing changes on multiple dates. The resident confirmed the lapses, and an LPN acknowledged the oversight. Observations revealed soiled dressings, and the DON and Administrator could not explain the failure to follow orders.
The facility failed to document a resident's skin graft and did not conduct weekly skin assessments for two residents with known skin impairments. A resident with a new skin graft had no documentation of the wound's condition, while two other residents did not receive weekly skin assessments as required by the facility's policy. The DON acknowledged these deficiencies during a surveyor interview.
A resident with a history of fractures and anticoagulant use was prescribed 7500 units of heparin daily. However, due to a transcription error, the resident received only 5000 units daily for nearly two months. The error was identified during a survey, and the DON acknowledged the mistake.
The facility failed to maintain required hospice documentation for two residents receiving hospice care. Essential documents, such as the hospice plan of care and physician orders, were missing from the records. Interviews revealed that the facility did not have individual hospice binders, and the necessary documents were not available in the electronic medical records.
The facility did not implement Enhanced Barrier Precautions (EBP) for residents with wounds and an MDRO infection. Observations showed the absence of isolation carts or signage for three residents with wounds and one with an ESBL infection. Staff interviews confirmed the oversight, despite acknowledging the residents' conditions.
A resident with multiple pressure ulcers did not receive adequate care, as the facility failed to update wound vac therapy orders and document treatments. An LPN did not follow proper infection control protocols during wound care, risking cross-contamination. The facility also neglected to document weekly assessments of the ulcers, contrary to the care plan.
Failure to Respond to Repeated Dysphagia-Related Choking Episodes
Penalty
Summary
The facility failed to provide adequate supervision and timely intervention for a resident with Parkinson’s disease and documented dysphagia, resulting in repeated choking and coughing episodes during meals and medication administration. The resident had a physician order for a no added salt diet with regular texture and regular liquids, and the care plan identified mild oral pharyngeal dysphagia with instructions to report changes to the medical provider. Progress notes documented coughing during meals, repeated coughing episodes, a choking episode during dinner, and choking during the medication pass over several days, but the record did not show that the provider was notified of these changes at the time they occurred. The record also did not show that staff implemented interventions after the coughing and choking episodes to prevent further events. A referral to therapy was completed with choking and frequent coughing marked as signs of aspiration, and speech therapy later evaluated the resident. During interviews, the Unit Manager, NP, Administrator, Interim DNS, and Speech Therapist acknowledged they could not find evidence that the provider had been notified of the resident’s increased coughing and choking or that an intervention had been put in place after the earlier episodes. An RN who documented the choking episodes stated he did not notify the provider, did not remove the meal tray or replace it with a softer option, and did not move the resident to a supervised location for meals. On the following day after the repeated episodes, the resident was found blue in color and actively choking, requiring staff to provide back slaps and remove food from the mouth with a finger sweep. The provider was then notified and new orders were obtained, including a chest x-ray, vital signs for 24 hours, and a diet downgrade to pureed consistency. The report states that the failure to notify the provider and implement interventions on the earlier dates resulted in the resident being found actively choking and placed in Immediate Jeopardy.
Missed Lasix Doses and Incomplete Daily Weights for Resident With CHF and COPD
Penalty
Summary
The facility failed to provide treatment and services according to physician orders for a resident admitted with acute on chronic diastolic congestive heart failure and chronic obstructive pulmonary disease. The resident was observed with edema to the upper and lower extremities, and the care plan addressed altered respiratory status with interventions to administer medications per MD/NP order. A handwritten physician order dated 11/14/2025 directed Lasix 20 mg every afternoon for 4 days, and an additional order dated 11/17/2025 extended Lasix 20 mg every evening for 11/18/2025 and 11/19/2025, for a total of 6 days of extra Lasix. The medication administration record showed the resident received only 4 additional doses of Lasix on 11/15/2025, 11/16/2025, 11/17/2025, and 11/18/2025, with the 11/14/2025 and 11/19/2025 doses not signed off as administered. The Unit Manager acknowledged that the resident did not receive the 6 days of Lasix as ordered and did not receive a dose on 11/19/2025. The NP also stated she would have expected the Lasix order to have been administered for a total of 6 days. The resident’s weight increased from 155.2 lbs on 10/26/2025 to 171.0 lbs on 11/18/2025. A progress note documented increased weight gain over 3 weeks, a 2.4-pound gain in 4 days, shortness of breath on exertion, and oxygen use at 3 liters, leading to an order for daily weights. However, the record and weight log did not show weights obtained on 11/17/2025 and 11/19/2025. Staff later noted the resident had difficulty breathing, pursed lip breathing, and a respiratory rate of 30 breaths per minute, and the resident was transferred to the hospital for evaluation; the hospital discharge summary stated that although COPD exacerbation was favored, CHF exacerbation could not be ruled out.
Failure to Respond to Repeated Choking Episodes
Penalty
Summary
The facility failed to ensure that Registered Nurse Staff F was competent to provide nursing services related to acute changes in condition, resulting in actual harm to Resident ID #9. Resident ID #9 was admitted with diagnoses including Parkinson disease and dysphagia, and the care plan directed staff to report any changes to the medical provider. Staff F completed competency training on observing and reporting changes in condition, but progress notes authored by Staff F documented that the resident choked on food during dinner and later choked during the medication pass, even though the resident was eventually able to swallow the pills. The record did not show that Staff F notified the provider after either choking episode, and it also did not show that an intervention was implemented to prevent further choking. On 10/28/2025, the resident was found with a blue face and actively choking, requiring back slaps and a finger sweep to remove food from the mouth. The provider was then notified, and orders were obtained for a chest x-ray, 24-hour vital signs, and a diet downgrade to pureed consistency. The resident complained of shortness of breath with crackles noted at both lung bases, and the record indicated signs of aspiration pneumonia.
Unnecessary Medication Administration and Failure to Follow Ordered Parameters
Penalty
Summary
The facility failed to ensure that residents’ drug regimens were free from unnecessary medications for three residents reviewed. Resident ID #4 had diagnoses including hypotension and heart failure and was ordered Metoprolol Succinate 25 mg with instructions to hold if heart rate was less than 60 beats per minute or systolic blood pressure was less than 100, yet the November 2025 MAR showed the medication was administered on 13 of 19 days without a documented heart rate. The same resident also had an order for Losartan Potassium 25 mg to be held for systolic blood pressure less than 110, but the MAR showed it was given on multiple dates when systolic blood pressure readings were below that parameter. Staff acknowledged that the heart rate was not documented and that Losartan was administered outside the ordered parameters. Resident ID #83, who had diagnoses including heart failure and dementia, had an order for Metoprolol Succinate 100 mg to be held for systolic blood pressure less than 110 or heart rate less than 60, but the MAR showed the medication was administered when the blood pressure was 103/64. Resident ID #79, who had chronic pain, had orders for Hydrocodone-Acetaminophen 10-325 mg every 6 hours as needed and Acetaminophen 500 mg, 2 tablets every 8 hours as needed, with instructions that total Acetaminophen not exceed 3000 mg in 24 hours. On 11/16/2025, the MAR showed the resident received 4 doses of Hydrocodone-Acetaminophen and 2 doses of Acetaminophen for a total of 3300 mg of Acetaminophen in 24 hours. Staff acknowledged the excessive Acetaminophen dose, and the Interim DNS stated she would have expected staff to follow the physician’s orders.
Failure to Issue SNFABN When Medicare Part A Coverage Ended
Penalty
Summary
The facility failed to properly provide notice to residents and/or their representatives when Medicare Part A coverage ended and liability for non-covered services changed, related to the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) of Non-coverage form. Review of CMS Form 100-55 stated that SNFs must issue the SNFABN to Original Medicare beneficiaries before providing care that Medicare usually covers but may not pay for in that instance, and the facility policy on Room and Care Medicare Part A Billing stated that the SNF ABN must be delivered prior to the change of financial liability after completion of Traditional Part A benefits. Record review showed that Resident ID #17’s last covered day of Medicare Part A services was 5/30/2025, Resident ID #22’s was 10/24/2025, and Resident ID #30’s was 10/22/2025. For all three residents, the record review failed to show evidence that the resident and/or representative was issued the SNFABN form. During interview, MDS Nurses Staff A and Staff B acknowledged that the residents or their representatives were not issued the SNFABN form and stated that they should have been. The Administrator and Interim DON were also unable to provide evidence that the required notice had been given.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to meet professional standards of quality by not following physician's orders for wound care for a resident. The resident, who was admitted with pressure ulcers on the left hip, sacral region, and left buttock, had specific physician's orders for daily dressing changes using Medihoney and Allevyn foam dressings for the hip and sacrum, and Biostep with a bordered foam dressing for the buttock. However, the Treatment Administration Record for September 2024 showed that these dressings were not changed on several dates, specifically 9/9, 9/11, and 9/12. During interviews, the resident confirmed that the dressings were not changed daily as ordered. A Licensed Practical Nurse (LPN) acknowledged the oversight after reviewing the medical record. An observation by the surveyor confirmed that the dressings were dated 9/11 and were visibly soiled, indicating they had not been changed as required. The Director of Nursing Services and the Administrator were unable to provide an explanation or documentation of any refusal by the resident to have the dressings changed.
Failure to Document and Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive care plan. Specifically, Resident ID #24, who was admitted with heart failure and skin cancer, had a new skin graft on the left upper arm that required daily dressing changes. However, there was no documentation in the medical record regarding the skin graft, including details about the wound's condition, edges, and surrounding tissue, as required by regulation. The Director of Nursing Services acknowledged the lack of documentation during a surveyor interview. Additionally, the facility did not conduct weekly skin assessments for residents with known skin impairments, as per their policy. Resident ID #9, with type II diabetes mellitus and peripheral vascular disease, did not receive weekly skin assessments for five consecutive weeks, despite being at risk for skin impairment. A large fluid-filled blister was later discovered on the resident's left shin. Similarly, Resident ID #257, admitted with cellulitis and peripheral vascular disease, did not have weekly skin assessments for two weeks following the identification of blisters in the abdominal folds. The Director of Nursing Services confirmed the failure to follow the facility's policy and the residents' care plans regarding skin assessments.
Medication Error: Incorrect Heparin Dosage
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. The resident, who was admitted with multiple fractures and a long-term use of anticoagulants, had a hospital discharge order for heparin at a dosage of 7500 units daily. However, upon review, it was found that the order was inaccurately transcribed by the facility as 5000 units daily. This transcription error resulted in the resident receiving an incorrect dosage of heparin from the time of admission until the error was identified by a surveyor nearly two months later. The Director of Nursing Services acknowledged the transcription error during an interview with the surveyor.
Failure to Maintain Required Hospice Documentation
Penalty
Summary
The facility failed to ensure that hospice services met professional standards for two residents receiving hospice care. For one resident, admitted in December 2023 with Alzheimer's disease, the facility's records lacked essential hospice documentation, including the most recent hospice plan of care, hospice election form, physician certification and recertification of terminal illness, contact information for hospice personnel, instructions for accessing the hospice's 24-hour on-call system, hospice medication information, and physician orders. Similarly, another resident, admitted in April 2022 with diverticulosis, also had missing hospice documentation after starting hospice services in April 2024. Interviews with the facility's Administrator and Director of Nursing Services (DNS) revealed that the facility did not maintain individual hospice binders for each resident receiving hospice services. Instead, hospice documents were expected to be scanned into the electronic medical records. However, the DNS was unable to provide the required hospice documents for the two residents during the survey. The deficiency was identified when surveyors brought the issue to the facility's attention, prompting the facility to obtain and place the necessary hospice documents into the residents' charts.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for residents with wounds and a Multi-Drug Resistant Organism (MDRO) infection. Specifically, three residents with wounds and one resident with an Extended Spectrum Beta Lactamase (ESBL) infection were not placed on EBP, which involves using gowns and gloves during high-contact care activities. Surveyor observations from September 3 to September 6, 2024, revealed the absence of isolation carts or signage indicating the need for EBP outside the rooms of these residents. Resident ID #24 had a skin graft and required regular dressing changes, Resident ID #28 had multiple pressure ulcers, and Resident ID #267 had a diabetic foot ulcer, all of which necessitated EBP. Additionally, Resident ID #258, with a history of ESBL in the urine, was not placed on EBP until after the surveyor's intervention. Interviews with the Director of Nursing Services (DNS) and other staff confirmed the oversight, as they acknowledged the residents' conditions but failed to implement the necessary precautions.
Deficient Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care for a resident with multiple pressure ulcers, including a stage 3 ulcer on the right hip and a stage 4 ulcer on the sacral region. The resident was readmitted with a physician's order for wound vac therapy, which was not updated following a wound clinic appointment. The order lacked details on the type of foam dressing to be used, and the addition of adaptic to the tendon was not included in the updated orders, contrary to the recommendations from the wound clinic. During an observation, a Licensed Practical Nurse (LPN) was seen performing wound care without following proper infection control protocols. The LPN did not change gloves after removing a soiled dressing and proceeded to touch clean surfaces and apply a new dressing, which could potentially lead to cross-contamination. The resident was on contact precautions due to a positive MRSA test, emphasizing the need for strict adherence to infection control practices. The facility also failed to document the completion of wound treatments on several dates, as evidenced by blank entries in the Treatment Administration Record (TAR). There was no documentation of the treatments being completed or refused by the resident. Additionally, the facility did not follow its care plan for weekly assessment and documentation of the pressure ulcers, as there were no records of measurements or wound status for two weeks following an initial skin assessment.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near South Kingstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Kingstown Nurs. & Rehab Ctr | 4.7 mi | ★★★★★ | 2 | 1 |
| South County Eden Operations Llc Dba Lakeside Nurs | 7.6 mi | ★★★★★ | 0 | 0 |
| Roberts Health Centre Inc | 8.9 mi | ★★★★★ | 5 | 0 |
| Village House Nursing & Rehabilitation Center | 9.3 mi | ★★★★★ | 6 | 0 |
| Kingston Center For Rehabilitation And Health Care | 10 mi | ★★★★★ | 0 | 0 |
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