Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at South Kingstown Nurs. & Rehab Ctr during CMS and state inspections, most recent first.
A resident who was continent on admission and able to ambulate with a RW and staff assist was repeatedly denied toileting help by an NA on 3rd shift. The NA told the resident to void in the brief and did not provide incontinence care, leaving the resident saturated in urine. Afterward, the resident developed urinary frequency and burning, was treated for a UTI, and the surgical dressing became urine-saturated with subsequent incision redness, maceration, and drainage requiring an unscheduled ortho visit.
Failure to accommodate a resident's preference to get out of bed. A cognitively intact resident with COPD, encephalopathy, and colostomy complications had documented preferences for religious services and going outside for fresh air, but staff could not show the resident refused OOB care. The resident said staff did not offer to get him/her out of bed and wanted a change of position and to go outside. CNA and LPN interviews could not recall the last time the resident was OOB, OT said the resident had previously been OOB several times a week for 6+ hours, and the DON could not provide evidence of refusals.
Failure to Notify Physician When Metoprolol Was Held: A resident with cardiomyopathy and atrial fibrillation had an order for metoprolol tartrate with instructions to hold for HR below 55 bpm and notify the physician. The MAR showed the medication was held multiple times for low or undocumented HR, but the record did not show physician notification, and an LPN and the DON could not find evidence that the physician had been notified.
A resident with cardiomyopathy and atrial fibrillation had an order for metoprolol tartrate 25 mg BID to be held only if HR was below 55 bpm and the physician notified. MAR review showed multiple doses were held for HRs above the ordered parameter, and several held doses had no documented HR. An LPN acknowledged the doses were given outside the HR parameters, and the DON could not provide evidence the medication was administered as ordered.
Advance Directive and EMR Code Status Mismatch: A resident's signed advance directive indicated Full Code, but the EMR banner and active physician order still showed DNR. An LPN stated the resident was DNR based on the EMR, another LPN acknowledged the code status had been updated in the advance directive but not in the EMR, and the DON said the code status order should match the advance directive.
A resident with dementia and pressure injuries to the left ankle and foot developed a stage III pressure ulcer on the left lateral foot. The wound provider recommended painting the wound with betadine and leaving it open to air, but staff transcribed and documented a different order for iodine, and the handwritten recommendation was not clarified despite being hard to read. The DON stated staff should repeat the order back to the provider or call for clarification.
A resident with a history of orthostatic hypotension and autonomic nervous system disorder was inadvertently given another resident’s medications during a morning med pass while an RN was training a newly hired LPN. The RN prepared multiple drugs intended for a roommate with Parkinson’s disease, DM, HTN, CAD, and depression, including two antihypertensives, an antidiabetic, an antiplatelet, an antiparkinsonian agent, an antidepressant, and vitamins, and handed them to the LPN to administer. The LPN entered the shared room, identified both residents, but administered the prepared medications to the wrong resident, then later disclosed the error when returning with the correct medications. Following the error, the affected resident’s BP progressively dropped, the resident became pale and weak, and was transferred and admitted to the hospital with hypotension, as confirmed by hospital records and acknowledged by the DON.
A resident with a history of urinary retention and obstructive uropathy had their Foley catheter replaced by an RN without a physician's order, using a different type and size than prescribed. The resident subsequently developed significant genital swelling and hematuria, requiring emergency transfer and was diagnosed with pyelonephritis. The care plan and physician's order had specified a scheduled catheter change at a urology appointment, but the nurse did not consult the physician before proceeding.
The facility did not ensure accurate and complete documentation of narcotic medication administration for three residents, as doses recorded in the narcotic log were not entered into the MAR. This discrepancy was identified after two residents reported not receiving their PRN pain medication, and the issue was confirmed by the DON during record review.
Surveyors found that several inhalers and a bottle of Lorazepam intensol in the facility were either outdated or lacked opening dates, contrary to professional principles. Nursing staff acknowledged the deficiencies, and the DON confirmed that medications should be dated and outdated ones discarded.
Surveyors observed that desserts were transported uncovered from the kitchen to two units in the facility, covering significant distances before being served to residents. Staff interviews confirmed that this was a longstanding practice, acknowledged by both a nursing assistant and the Food Service Director.
Two residents with cognitive impairments were involved in an altercation where one resident, with a history of aggressive behavior, slapped another on the head. The incident, witnessed by staff, resulted in an abrasion on the aggressor's hand. The facility failed to protect residents from abuse, as acknowledged by the Administrator.
Failure to Assist Continent Resident With Toileting and Incontinence Care
Penalty
Summary
The facility failed to keep a resident free from neglect when a Nursing Assistant refused repeated requests for toileting assistance during third shift. The resident was admitted with diagnoses including spinal stenosis and surgical aftercare following spinal surgery, was alert and oriented, and was documented on admission as continent of bowel and bladder, able to ambulate with a rolling walker and staff assistance, and requiring one-person assist with a gait belt and rolling walker per the care plan. Hospital discharge paperwork also indicated the resident was full weight bearing and encouraged to be up and walking. According to the report, the resident told staff that the Nursing Assistant would not help him/her to the bathroom, instructed him/her to void in the brief, and did not provide incontinence care before leaving. The resident later reported being incontinent of urine after multiple unanswered requests for help. The Nursing Assistant acknowledged refusing to assist the resident to the bathroom because the resident had not yet been assessed by physical therapy, and acknowledged not assisting with incontinence care prior to leaving the facility. After the incident, nursing documentation showed the resident developed urinary frequency and burning, was evaluated for a UTI, and was treated with antibiotics. The resident's surgical dressing was found saturated with urine and required a dressing change, and the incision later showed redness, maceration, and drainage, prompting an unscheduled orthopedic follow-up visit. The resident also reported becoming very upset and anxious because of the incident, and the Director of Nursing stated the resident had been able to transfer and ambulate to the bathroom with assistance on admission.
Failure to Accommodate Resident's Preference to Get Out of Bed
Penalty
Summary
Reasonably accommodating the needs and preferences of a cognitively intact resident was not provided when Resident ID #72 was not getting out of bed despite documented preferences and prior therapy records showing the resident had previously been out of bed for extended periods. The resident was admitted with diagnoses including COPD, encephalopathy, and complications of colostomy, and the admission MDS showed a BIMS score of 13 out of 15 and dependence on two staff members for transfers out of bed. The MDS preferences section indicated it was very important for the resident to participate in religious services or practices and to go outside for fresh air when the weather was good. The care plan included an intervention to encourage the resident to get out of bed while respecting the resident's decision to stay in bed if chosen, but the record did not show evidence that the resident refused to get out of bed. The resident told the surveyor staff did not offer to get him/her out of bed and wanted to get out of bed for a change of positioning and to go outside. Staff interviews showed the CNA and LPN could not recall the last time the resident was out of bed and acknowledged there was no documentation of refusal, the OT assistant stated the resident had previously been out of bed 3 to 4 times a week for 6 or more hours and had not refused treatments, and the Activities Director said the resident had last been out of bed for a social activity months earlier. The DON stated residents were expected to be offered and encouraged to get out of bed daily but could not provide evidence that this resident had refused.
Failure to Notify Physician When Metoprolol Was Held
Penalty
Summary
The facility failed to meet professional standards of quality by not following a physician’s order for metoprolol tartrate for Resident ID #38. The resident was admitted in March 2026 with diagnoses including cardiomyopathy and atrial fibrillation. On 4/6/2026, the resident had an order for metoprolol tartrate 25 mg twice daily with instructions to hold the medication if the heart rate was below 55 bpm and to notify the physician. Review of the MAR from 4/7/2026 through 5/7/2026 showed the medication was held multiple times, including instances where the heart rate was documented below the ordered parameter and instances where no heart rate was documented. The record did not show that the physician was notified when the medication was held on those dates and times. Surveyor interviews with an LPN and the DON confirmed they could not find evidence in the record that the physician had been notified. The report states the physician was not notified 16 of 19 times the medication was held in April and 5 of 6 times it was held in May.
Medication Held Outside Ordered Heart Rate Parameters
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from significant medication errors for a resident with cardiomyopathy and atrial fibrillation. The resident had a physician's order dated 4/6/2026 for metoprolol tartrate 25 mg twice daily with instructions to hold the medication if the heart rate was below 55 bpm and to notify the physician. Review of the April and May 2026 MARs showed that metoprolol was held for heart rates above the ordered parameter on multiple occasions, including doses held for heart rates of 57, 58, 67, 56, and 57 bpm. The MAR also showed several held doses with no documented heart rate recorded. During interview, an LPN acknowledged that the listed doses of metoprolol were given outside the heart rate parameters, and the DON could not provide evidence that the medication was administered as ordered on the identified dates.
Advance Directive and EMR Code Status Mismatch
Penalty
Summary
The facility failed to ensure that a resident's formulated advance directive was followed because the resident's signed advance directive and the electronic medical record (EMR) did not match. Clinical record review showed a signed advance directive dated 4/27/2026 in which the resident selected Full Code and indicated that 911 should be called, with all resuscitative and aggressive measures provided and transfer to the hospital. However, the resident also had a physician order for Do Not Resuscitate (DNR) with a start date of 5/27/2025, and this order remained active until 5/8/2026 after the surveyor brought it to the facility's attention. The resident's chart also displayed DNR on the banner at the top of the EMR. During interviews on 5/8/2026, an LPN stated the resident's code status was DNR and that resuscitative measures would not be provided, and another LPN stated she would look at the EMR to determine code status and acknowledged that the resident had updated the code status to Full Code on 4/27/2026, but it had not been updated in the EMR. The DON stated she would expect the code status order to match the resident's advance directive.
Incorrect wound order transcription for resident with stage III pressure ulcer
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for a resident with dementia who was readmitted to the facility in March 2026 with pressure injuries to the left ankle and foot. The care plan initiated on 3/3/2026 directed staff to monitor and treat the left ankle and foot wounds as ordered. On 5/5/2026, the skin ulcer documentation identified a stage III pressure ulcer on the resident’s left lateral foot, and the wound provider, Nurse Practitioner Staff F, documented an order to paint the wound with betadine. That same day, RN Staff G documented that the wound nurse had given a new order to apply iodine to the left lateral foot and that the order was reviewed and approved by the MD. However, Staff F later stated she recommended painting the wound with betadine and leaving it open to air, and Staff G stated she did not confirm the handwritten recommendation because it was hard to read. RN Staff H acknowledged she transcribed the incorrect order and said the order should have been to paint the wound with betadine and leave it open to air based on Staff F’s recommendation. The DON stated staff would be expected to repeat the order back to the provider or call to clarify if needed.
Significant Medication Error During Training Medication Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when one resident was inadvertently administered multiple medications prescribed for a roommate. The facility’s Medication Administration Safety Program policy required that the same person who prepares medications must administer them and that the licensed staff member must confirm the resident’s identity prior to administration. On the date of the incident, RN Staff A was training newly hired LPN Staff B during the morning medication pass and prepared a set of medications at the cart for Resident ID #2, including two antihypertensives, an antidiabetic, an antiplatelet, an antiparkinsonian agent, an antidepressant, a multivitamin, and two additional vitamins. Resident ID #1 had been admitted in January 2026 with diagnoses including orthostatic hypotension, autonomic nervous system disorder, and thrombocytopenia. Resident ID #2 had been admitted in July 2025 with diagnoses including Parkinson’s disease, diabetes mellitus, high blood pressure, major depressive disorder, and coronary artery disease. After RN Staff A prepared Resident ID #2’s medications and handed them to LPN Staff B with instructions to administer them to Resident ID #2, Staff B went into the shared room, identified both residents, but proceeded to administer the medications intended for Resident ID #2 to Resident ID #1 instead. Staff B then returned to the medication cart, where RN Staff A had prepared Resident ID #1’s medications, and both staff re-entered the room to administer those medications. At that time, LPN Staff B informed RN Staff A that Resident ID #1 had already received the medications intended for Resident ID #2. Subsequent nursing documentation showed that immediately after the error was identified, Resident ID #1’s blood pressure was 99/61, and later readings declined to 78/40 and then 63/37, with the resident becoming pale and weak. The resident’s condition required transfer to the hospital, where continuity of care documentation indicated arrival to the emergency department with hypotension, dizziness, and lightheadedness, and the need for IV fluid boluses for systolic blood pressure readings in the 80s. The DON acknowledged during interview that Resident ID #1 inadvertently received Resident ID #2’s medications and was admitted to the hospital with hypotension as a result.
Catheter Replaced Without Physician Order Resulting in Complications
Penalty
Summary
A deficiency occurred when a resident with a history of obstructive and reflux uropathy and urinary retention, who had an indwelling Foley catheter per physician order, had their catheter replaced by a registered nurse without a physician's order. The resident's care plan included monitoring for urinary tract infection and the physician's order specified the use of an 18 French Foley catheter with a 10 cc balloon, with a scheduled urology appointment for catheter replacement. Despite these instructions, the nurse removed the existing catheter and inserted a different type and size (16 French, 5 cc balloon, coude tip) after observing low urine output and unsuccessful flushing, without consulting the physician or obtaining a new order. Following the catheter change, the resident exhibited significant swelling of the genitalia and hematuria, prompting transfer to the emergency room, where the diagnosis was pyelonephritis. Record review confirmed there was no physician's order for the catheter change prior to the scheduled appointment, and the Director of Nursing Services confirmed that the nurse should have contacted the physician for further recommendations rather than proceeding with the catheter replacement.
Failure to Accurately Document Narcotic Medication Administration
Penalty
Summary
The facility failed to ensure that resident medical records were complete and accurately documented regarding the administration of narcotic medications for three residents. Specifically, there were discrepancies between the narcotic administration log and the Medication Administration Records (MAR) for these residents. For one resident with lumbar spinal stenosis and cognitive communication deficit, the narcotic log showed that oxycodone was administered, but this was not documented in the MAR. Another resident with spondylolisthesis had two doses of oxycodone recorded in the narcotic log, but these were not reflected in the MAR. A third resident with encephalopathy and multiple cancerous tumors also had a dose of oxycodone documented in the narcotic log but not in the MAR. These documentation failures were identified following a facility-reported incident in which two alert and oriented residents reported not receiving their PRN narcotic pain medication after multiple requests. The discrepancies were confirmed during a review of the records and acknowledged by the Director of Nursing Services. The lack of proper documentation in the MAR for administered narcotic medications was not in accordance with accepted professional standards and facility policy.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles. During a surveyor observation, it was found that several inhalers on the Pond View, Tradewinds, and Robin's Way unit medication carts were either outdated or lacked the necessary opening dates. Specifically, a Wixela inhaler on the Pond View unit was opened on 12/12 and was outdated, while an Arnuity inhaler and a Treligy Ellipta inhaler were opened without dates. Similarly, on the Tradewinds unit, a Treligy Ellipta inhaler was found opened without a date. On the Robin's Way unit, an Anoro Ellipta inhaler was outdated, and another Anoro inhaler, along with two Treligy Ellipta inhalers and a Combivent Respimat inhaler, were opened without dates. Additionally, in the Robin's Way medication room, a bottle of Lorazepam intensol was found opened without a date, contrary to the manufacturer's instructions to discard it 90 days after opening. Interviews with the nursing staff confirmed the lack of proper labeling and acknowledgment of the outdated medications. The Director of Nursing Services also confirmed that medications should be dated when opened and outdated inhalers should be discarded.
Uncovered Desserts During Transport in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards for food safety during the distribution and serving of food, as observed by surveyors. Specifically, on two separate occasions, desserts were transported uncovered from the kitchen to the Pond View and Tradewinds units, covering distances of approximately 300 and 400 feet, respectively. This practice was observed during the lunch meal service on both units, and the desserts were subsequently distributed to residents without being covered. Interviews with staff confirmed the deficiency. A nursing assistant acknowledged that the desserts were not covered during transportation. Additionally, the Food Service Director admitted that it was the facility's practice not to cover desserts during transport, a practice that had been in place for several years. This acknowledgment by the staff and the director highlights a systemic issue in the facility's food service operations, leading to the deficiency noted by the surveyors.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by an incident involving two residents. Resident ID #2, who has a history of physical and verbal abuse, was witnessed by a staff member slapping Resident ID #1 on the back of the head. In response, Resident ID #1 slapped the hand of Resident ID #2. Both residents have cognitive impairments, with Resident ID #1 having a BIMS score indicating moderately impaired cognition and Resident ID #2 unable to complete the BIMS assessment due to cognitive limitations. The incident was reported to the Rhode Island Department of Health, and the facility's Administrator acknowledged the occurrence. Resident ID #2 sustained an abrasion on the back of the hand as a result of the altercation. The facility's failure to prevent this incident highlights a deficiency in protecting residents from abuse, particularly given Resident ID #2's known history of aggressive behaviors.
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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 West Kingston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Adviniacare Scallop Shell, Llc | 5 mi | ★★★★★ | 6 | 1 |
| Kingston Center For Rehabilitation And Health Care | 5.3 mi | ★★★★★ | 0 | 0 |
| South County Eden Operations Llc Dba Lakeside Nurs | 5.6 mi | ★★★★★ | 6 | 0 |
| Roberts Health Centre Inc | 6.5 mi | ★★★★★ | 5 | 0 |
| Saint Elizabeth Home East Greenwich | 10.6 mi | ★★★★★ | 5 | 0 |
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