South Kingstown Nurs. & Rehab Ctr

In the surveyor’s words

From the most serious findings on record at South Kingstown Nurs. & Rehab Ctr, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Feb 18, 2026

  Based on clinical record review and staff interview, the facility failed to ensure residents were free from significant medication errors for 1 of 3 residents reviewed. Resident ID #1 was inadvertently administered multiple medications prescribed for his/her roommate, Resident ID #2. The medications included two antihypertensives (a medication prescribed to treat high blood pressure), an antidiabetic (a medication prescribed to lower high blood sugar), an antiplatelet (a medication prescribed to prevent blood clots from forming), an antiparkinsonian agent (a medication prescribed to treat Parkinson's Disease), an antidepressant (a medication prescribed to treat depression), a multivitamin, and two additional vitamins. […]

• Actual harm, isolatedF600May 12, 2026

  Based on surveyor observation, clinical record review, and staff and resident interviews, the facility failed to ensure residents remained free from abuse and neglect for 1 of 1 resident reviewed when staff refused the resident's repeated requests for toileting assistance. Specifically, the facility failed to provide necessary care and services to a continent resident, resulting in the resident being left heavily saturated in urine and forced into an incontinent episode. This failure caused actual harm, including the development of a urinary tract infection (UTI) and psychosocial harm, for Resident ID #124.Findings are as follows:Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/23/2026 revealed that Resident ID #124 alleged that Nursing… […]

• No harm, potential for more than minimal, patternF558May 12, 2026

  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… […]

• No harm, potential for more than minimal, patternF658May 12, 2026

  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… […]

• No harm, potential for more than minimal, patternF760May 12, 2026

  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. […]