South Kingstown Nurs. & Rehab Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, the facility failed to provide reasonable accommodation of resident needs and preferences, for 1 of 1 resident reviewed related to not getting out of bed, Resident ID #72.Findings are as follows:Record review revealed the resident was originally admitted to the facility in February of 2025 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (a lung condition that causes long-term breathing problems by limiting airflow), encephalopathy (a generalized dysfunction of the brain), and complications of colostomy (a surgical procedure that creates an opening in the abdominal wall, bringing a portion of the large intestine to the surface to allow stool to exit).Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 13 out of 15, indicating the resident is cognitively intact. Further review revealed that the resident is dependent on two staff members for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, the facility failed to meet professional standards of quality regarding not following physician's orders for 1 of 1 resident reviewed related to medications with heart rate (HR) parameters, Resident ID #38.Findings are as follows:Record review of a facility policy titled, Medication Administration Safety Program revealed in part, .the physician's order must be verified before the medication is given.when medication are held/refused, the MD is to be notified timely.Record review revealed the resident was admitted to the facility in March of 2026 with diagnoses including, but not limited to, cardiomyopathy (a disease effecting the heart muscle which causes the heart to have a harder time pumping blood), and atrial fibrillation (an irregular and often very rapid heart rhythm).Record review revealed the following physician's order:4/6/2026-Metoprolol tartrate 25 milligrams (mg) twice daily. The order contained instructions to hold for a heart rate below 55 beats per minute (bpm), and to notify the physician.A review of the Medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, the facility failed to ensure a resident's drug regimen is free from significant medication errors for 1 of 1 resident reviewed for medication errors due to heart rate parameters, Resident ID #38. Findings are as follows:Record review revealed the resident was admitted to the facility in March of 2026 with diagnoses including, but not limited to, cardiomyopathy (a disease effecting the heart muscle which causes the heart to have a harder time pumping blood), and atrial fibrillation (an irregular and often very rapid heart rhythm).Record review revealed the following physician's order:4/6/2026-Metoprolol tartrate 25 milligrams (mg) twice daily. The order contained instructions to hold for a heart rate below 55 beats per minute (bpm), and to notify the physician.A review of the April and May 2026, Medication Administration Records (MAR) revealed the medication was held for a heart rate above 55 bpm on the following dates and times:4/14/2026- 7:00 AM to 11:00 AM dose- held for a heart rate of 574/22/2026- 7:00 AM to 11:00 AM dose-…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, the facility failed to ensure that the resident's formulated advance directive would be followed due to inconsistency between the signed advanced directive and the electronic medical record (EMR) for 1 of 1 resident reviewed for a change in code status, Resident ID #86.Findings are as follows:Record review revealed a signed Advanced Directive dated 4/27/2026, indicating that the resident checked Full Code, .911 will be called. All resuscitative and aggressive measure are provided and I will be transferred to the hospital.Record review revealed a physician's order for Do Not Resuscitate (DNR) with a start date of 5/27/2025. This order was not discontinued until 5/8/2026, after the surveyor brought it to the facility's attention.Record review of the resident's chart revealed that DNR was also displayed on the banner at the top of his/her medical record.During a surveyor interview on 5/8/2026 at 9:47 AM with Licensed Practical Nurse (LPN), Staff D, after reviewing the resident's EMR banner and the physician's order, she stated that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, the facility failed to ensure that a resident receives care, consistent with professional standards of practice to prevent pressure ulcers (localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure) for 1 of 2 residents reviewed with pressure ulcers, Resident ID #3.Findings are as follows:Record review revealed the resident was readmitted to the facility in March of 2026 with a diagnosis including, but not limited to, dementia.Review of a care plan focus area initiated on 3/3/2026 revealed the resident was admitted to the facility with pressure injuries to his/her left ankle and foot. An intervention includes, but is not limited to, monitor and treat areas to left ankle and foot, as ordered.Record review revealed a document titled, Skin Ulcer Documentation, dated 5/5/2026 which revealed the resident has a stage III pressure ulcer (full-thickness skin loss potentially extending into the subcutaneous tissue layer) on his/her left lateral foot.Review of a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 2 residents reviewed with an indwelling Foley catheter (a flexible tube that collects urine from the bladder and empties the urine into a drainage bag), Resident ID #3. Findings are as follows: Review of a facility reported incident received by the Rhode Island Department of Health on 4/9/2025 revealed that Resident ID #3 had a Foley catheter replaced at the facility without a physician's order. Review of Lippincott Nursing Procedures Manual Ninth Edition, last revised in 2023, states in part, .Indwelling Catheter Care and Removal .Indwelling Urinary Catheter Insertion .verify the practitioner's order . Record review revealed the resident was admitted to the facility in December of 2024 with diagnoses including, but not limited to, obstructive (a structural or functional hindrance of normal urine flow) and reflux (a condition where there is a backflow of urine into the kidney) uropathy and retention of urine. Review of the resident's care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it has been determined that the facility failed to ensure that resident records are complete and accurately documented, relative to narcotic medication administration, for 3 of 6 residents reviewed, Resident ID #s 2, 4, and 5. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/9/2025 indicated that two alert and oriented residents reported they did not receive their PRN (as needed) narcotic pain medication overnight after requesting it multiple times and that there appeared to be discrepancies between the narcotic log book and the resident's Medication Administration Records (MAR). According to the Lippincott Nursing Procedures Ninth Edition last revised in 2023 states in part, .Safe Administration Practices .Document all medications administered in the patient's MAR or EMAR [Electronic Medication Administration Record]. Include the medication strength, dose, route of administration, and date and time of administration . A. Record review revealed Resident ID #2 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 1 of 2 medication storage rooms observed and 3 of 4 medication carts observed. Findings are as follows: Review of the facility policy dated 1/2021, titled, Medication Storage states in part, .POLICY: It is the policy of this facility that medications and biological's are stored properly, following manufacturers or provider pharmacy recommendations .14. Outdated, contaminated, discontinued or deteriorated medications .should be immediately removed from stock . 1a. During a surveyor observation on 2/11/2025 at 8:50 AM of the Pond View unit medication cart, in the presence of Registered Nurse (RN), Staff A, the following was revealed: -One Wixela inhaler, opened with a date of 12/12. Review of the manufacturer's instructions indicate to discard the inhaler one month after opening. -One Arnuity inhaler, opened without a date. Review of the manufacturer's instructions indicate to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that they distribute and serve food in accordance with professional standards for food safety relative to 2 of 4 units observed during the lunch meal service. Findings are as follows: According to the, State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, last updated in August of 2024, states in part, .'Food Service' means the processes involved in actively serving food to the resident. When actively serving residents in a dining room or outside a resident's room where trained staff are serving food/beverage choices directly from a mobile food cart or steam table, there is no need for food to be covered. However, food should be covered when traveling a distance (i.e., down a hallway, to a different unit or floor) . A surveyor observation on 2/11/2025 at approximately 12:00 PM of the Pond View unit, revealed a sheet pan rack (a heavy-duty aluminum rack with uniformly spaced tray slides) being transported from the kitchen to the unit,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, and resident interview, it has been determined that the facility failed to protect a resident's right to be free from abuse for 2 of 2 residents reviewed, Resident ID #s 1 and 2. Findings are as follows: Record review of facility reported incident submitted to the Rhode Island Department of Health on 9/30/2024 indicates that Resident ID #2 was witnessed by staff slapping Resident ID #1 on the back of his/her head at which time, Resident ID #1 then slapped the hand of Resident ID #2. Record review revealed that Resident ID #1 was admitted to the facility in November of 2021 with diagnoses including, but not limited to, Alzheimer's disease, dementia with agitation, cognitive communication deficit, adjustment disorder, anxiety disorder and major depressive disorder. Record review for Resident ID #1 revealed a Minimum Data Set (MDS) assessment dated [DATE] that revealed a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating moderately impaired cognition. A surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight for 1 of 2 residents reviewed for weight gain, Resident ID #11. Findings are as follows: Record review of an undated facility policy and procedure for Weight Loss/Gain Protocol and Heights, provided to the surveyor on 2/28/2024, states in part, .All residents are to be weighed upon admission and at least monthly; so as to monitor for weight loss or gain, to assess for underlying causes of weight loss or gain, to intervene accordingly and timely to allow for an optimal level for well-being .PROCEDURE: .For purpose of this policy, a significant weight discrepancy is defined as: .A loss/gain of 5% or greater within one month .When a significant weight loss/gain is noted (as defined above), the following interventions may be considered: 1. Reweigh all residents who are reported to have significant weight discrepancy in order to assess the accuracy of the weight. The reweigh shall be done within 2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident observed specific to finger stick blood glucose testing, Resident ID #194. Findings are as follows: Record review of a facility policy titled, Diabetes - Care of equipment SECTION: Infection Control, dated 3/11/2005 states in part, .It is the policy of this facility to develop and support Infection Control practices that are designed to prevent transmission of blood borne pathogens from diabetes-care procedures .4. Dispose of used lancets [used to obtain a blood sample from a finger] at the point of use in approved sharp containers . Record review of a document titled, Competency Validation for Blood Glucose Testing states in part, .discarding the used lancet after use in the sharps container . Record review revealed the resident was admitted to the facility in February of 2024, with a diagnosis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.