NORTH KINGSTOWN, RI - Federal health inspectors found Bayview Rehabilitation and Healthcare Center failed to ensure residents were protected from significant medication errors, according to a complaint investigation completed on December 1, 2025. The pharmacy service deficiency was one of three total citations issued to the facility during the inspection.
Medication Safety Deficiency Under Federal Review
The Centers for Medicare & Medicaid Services (CMS) cited Bayview Rehabilitation and Healthcare Center under regulatory tag F0760, which requires skilled nursing facilities to ensure residents are free from significant medication errors. The citation fell under the broader category of pharmacy service deficiencies, a critical area of oversight in long-term care settings.
Federal regulators classified the deficiency at Scope/Severity Level D, meaning the issue was isolated in nature and did not result in documented actual harm to residents. However, inspectors determined there was potential for more than minimal harm, a classification that signals the problem could have led to adverse outcomes if left unaddressed.
The distinction between "no actual harm" and "potential for more than minimal harm" is significant in federal nursing home oversight. Level D findings indicate that while no resident was directly injured by the medication error in question, the circumstances surrounding it created conditions where harm was a realistic possibility.
Why Medication Errors Present Serious Risks in Nursing Homes
Medication errors in skilled nursing facilities represent one of the most common and potentially dangerous categories of care failures. Nursing home residents typically take multiple medications simultaneously, with the average long-term care resident receiving seven to eight different medications daily. This high medication burden makes accurate administration, dosing, and monitoring essential.
Even a single medication error can trigger cascading health consequences. Incorrect dosing of blood thinners can lead to internal bleeding or stroke. Administering the wrong blood pressure medication can cause dangerous drops in blood pressure, increasing fall risk. Missed doses of antibiotics can allow infections to worsen or develop antibiotic resistance.
Proper medication management in a skilled nursing facility requires a multi-step process: physician orders must be accurately transcribed, pharmacy dispensing must be verified, nursing staff must administer the correct medication to the correct resident at the correct time, and ongoing monitoring must track for side effects or adverse reactions. A breakdown at any point in this chain constitutes a medication error under federal standards.
Federal Standards for Pharmacy Services
Under CMS regulations, nursing homes participating in Medicare and Medicaid programs must maintain pharmacy services that ensure each resident's drug regimen is free from significant medication errors. Facilities are required to have a licensed pharmacist review each resident's medication regimen at least monthly and report any irregularities to the attending physician and director of nursing.
The federal requirement under F0760 is not limited to administration errors alone. It encompasses the entire medication use process, including prescribing, dispensing, administering, and monitoring. Facilities must demonstrate that they have systems in place to prevent errors and protocols to respond when errors occur.
Facility Response and Correction Timeline
Bayview Rehabilitation and Healthcare Center submitted a plan of correction following the inspection findings. The facility reported that corrective measures were implemented as of December 22, 2025, approximately three weeks after the inspection concluded.
A plan of correction typically requires the facility to identify how the deficiency will be addressed for affected residents, outline systemic changes to prevent recurrence, and establish monitoring procedures to ensure sustained compliance. CMS may conduct follow-up inspections to verify that corrective actions have been effectively implemented.
Additional Citations
The medication error deficiency was not the sole finding during the December 2025 complaint investigation. Inspectors issued a total of three deficiencies to Bayview Rehabilitation and Healthcare Center during this inspection cycle, indicating that the complaint investigation revealed multiple areas requiring improvement.
Bayview Rehabilitation and Healthcare Center is a skilled nursing facility located in North Kingstown, Rhode Island. The full inspection report, including detailed findings for all three deficiencies, is available through the CMS Care Compare database and on the facility's profile at NursingHomeNews.org.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bayview Rehabilitation and Healthcare Center from 2025-12-01 including all violations, facility responses, and corrective action plans.
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