Bayview Rehabilitation And Healthcare Center
Inspection Findings
F-Tag F0658
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm or potential for actual harm
Based on record review and staff interview, the facility failed to ensure that services provided meet professional standards of quality relative to following physician's orders for 1 of 1 resident reviewed with an order for Midodrine (a medication prescribed to increase a person's blood pressure) and an order for a wound treatment, Resident ID #1.Findings are as follows:Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients.Record review revealed the resident was admitted to the facility in November of 2025 with a diagnosis including, but not limited to, hypotension (low blood pressure). 1. Record review of the provider's progress note dated 11/18/2025 at 11:53 PM, states in part, .Orders: midodrine 5mg [milligrams] PO [by mouth] TID [three times daily] prn [as needed] for systolic [the top number of a blood pressure reading] < 100 or diastolic [the bottom number of a blood pressure reading] < 60 x [times] 7 days.Record review revealed a physician's order dated 11/19/2025 for Midodrine 5 mg three times daily as needed for a systolic blood pressure less than 100, a diastolic blood pressure less than 60 (the normal blood pressure reading is 120/80). Record
review revealed an additional physician's order dated 11/18/2025 for vital signs every shift for 7 days.
Record review of the documented blood pressures revealed the following:-11/19/2025 at 2:08 AM, 84/60 -11/19/2025 at 6:19 AM, 76/59-11/19/2025 at 10:12 AM, 82/58-11/19/2025 at 10:34 PM, 99/62-11/20/2025 at 8:30 AM, 80/54-11/20/2025 at 10:30 AM, 79/51-11/20/2025 at 8:12 PM, 80/49-11/21/2025 at 5:40 AM, 96/68Record review of the November 2025 Medication Administration Record (MAR) failed to reveal evidence that the resident received the Midodrine as ordered, for the above-mentioned blood pressure readings.During a surveyor interview on 12/1/2025 at 3:04 PM with Registered Nurse, Staff A, she acknowledged that she did not administer the Midodrine when indicated, on 11/19/2025 for a blood pressure reading of 82/58 and on 11/20/2025 for a blood pressure reading of 79/51. During a surveyor
interview on 12/1/2025 at 3:45 PM with the Director of Nursing Services (DNS), she acknowledged the Midodrine was not administered as ordered, for the above-mentioned blood pressure readings.2. Record
review revealed a physician's order dated 11/19/2025 to cleanse the left posterior (back) calf with normal saline, pat dry, apply calcium alginate (a type of wound treatment), and cover with a bordered gauze, every evening shift.Record review of the November 2025 Treatment Administration Record revealed on the evening shift of 11/20/205, the wound treatment was not completed, and the nurse had documented that
the resident was sleeping. During a surveyor interview on 12/1/2025 at 3:45 PM with the DNS, she could not provide evidence that the resident's left posterior calf wound treatment was completed on 11/20/2025, as ordered.
Residents Affected - Some
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
12/01/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bayview Rehabilitation and Healthcare Center
860 North Quidnessett Road North Kingstown, RI 02852
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0757
F 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm or potential for actual harm
Based on record review and staff interview, the facility failed to ensure the resident's drug regimen was free from unnecessary medications for 1 of 1 resident reviewed receiving Metoprolol Tartrate (a medication prescribed to treat cardiac conditions and assists in lowering the blood pressure and heart rate), Resident ID #1.Findings are as follows:Record review revealed the resident was admitted to the facility in November of 2025 with diagnoses including, but not limited to, atrial fibrillation (an irregular and often rapid heart rhythm) and hypotension (low blood pressure).Record review of a nursing admission progress note dated 11/18/2025 revealed the resident's vital signs were obtained upon admission, and the highest blood pressure (BP) reading was 78/48 (normal blood pressure 120/80). The on-call provider was notified of his/her low blood pressure and parameters were ordered for the medication Metoprolol.Record review revealed a physician's order dated 11/18/2025 for Metoprolol Tartrate, give 12.5 milligrams (mg) by mouth twice daily, with parameters to hold the medication for a systolic blood pressure (the top number of a blood pressure reading) of less than 100. Additional review of the medication orders indicated that on 11/19/2025
the Metoprolol administration times were revised within the order by Registered Nurse, Staff C, and the ordered parameters to hold the medication for the systolic blood pressure readings that were initially entered, were no longer visible within the order.Record review revealed an additional physician's order dated 11/18/2025 for vital signs every shift for 7 days.Record review of the November 2025 Medication Administration Record (MAR) revealed the following BP readings:-11/18/2025, evening shift BP 84/60 -11/19/2025, day shift BP 82/58-11/19/2025, evening shift BP 82/58-11/20/2025, day shift BP 79/51-11/20/2025, evening shift BP 80/49 Record review of the November 2025 MAR revealed the Metoprolol was signed off as administered, on the following dates and shifts:-11/19/2025, evening shift-11/20/2025, day shift-11/20/2025, evening shiftDuring a surveyor interview on 12/1/2025 at 3:28 PM with the Certified Medication Technician, Staff B, she acknowledged that the MAR indicated she signed off that she had administered the Metoprolol on the evening of 11/19/2025 with a blood pressure of 82/58.During a surveyor interview on 12/1/2025 at 3:37 PM with the Director of Nursing, she acknowledged that the resident received the Metoprolol on 11/19/2025 and 11/20/2025 with the above-mentioned blood pressure readings. During a surveyor interview on 12/1/2025 at approximately 3:50 PM with the Registered Nurse, Staff C, she acknowledged that she revised the order on 11/19/2025 to reflect the appropriate medication administration times, but she was unaware that the medication parameters were subsequently removed from the order.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
12/01/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bayview Rehabilitation and Healthcare Center
860 North Quidnessett Road North Kingstown, RI 02852
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0760
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm or potential for actual harm
Based on record review and staff interview, the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed receiving Warfarin/Coumadin (an anticoagulant medication prescribed to treat and prevent harmful blood clots from forming or growing larger), Resident ID #3. Findings are as follows: Record review revealed the resident was admitted to the facility in November of 2025 with a diagnosis including, but not limited to, deep vein thrombosis (a blood clot that forms in the deep veins of the leg).Record review revealed a physician's order dated 11/7/2025 for Warfarin 3 milligrams (mg) by mouth, every evening, for treating/preventing blood clots until 11/13/2025.Record review revealed a physician's order dated 11/14/2025 for a PT/INR (a blood test that determines the continued dosing for Warfarin), one time on 11/14/2025.Record review revealed the PT/INR was obtained, as ordered, and resulted on 11/14/2025. Record review for 11/14/2025 failed to reveal evidence that the PT/INR results were reviewed or that the provider was notified of the results. Additional record review failed to reveal evidence that a new order for Warfarin was obtained for the resident's continued dosing for Warfarin therapy. Record review of the November 2025 Medication Administration Record (MAR) revealed, the resident received Warfarin daily for the month of November, since his/her admission, except on 11/14/2025 and 11/15/2025. Further review of the MAR revealed a physician's order was subsequently transcribed on 11/17/2025 for a Coumadin Alert, indicating that the resident receives Coumadin therapy and to ensure that there is a current Coumadin order in place every evening shift. Additionally, the Coumadin Alert order was signed off each shift by staff, with the resident's INR results documented and the current Coumadin dose.
During a surveyor interview on 12/1/2025 at 3:13 PM with Registered Nurse, Staff A, she revealed that she was the resident's nurse during the day shift on 11/14/2025 and the PT/INR may not have resulted before
the end of her shift. Additionally, she was unable to provide evidence of a progress note addressing the resident's PT/INR results on 11/14/2025 or that a Warfarin order was obtained on 11/14/2025 or 11/15/2025. During a surveyor interview on 12/1/2025 at 3:36 PM with the Director of Nursing, she revealed that the Coumadin Alert order is usually transcribed to ensure staff administering medications are aware when a resident is on Coumadin therapy and she acknowledged that the order was not transcribed until 11/17/2025. Additionally, the DNS acknowledged that the resident did not receive his/her Coumadin doses
on 11/14/2025 or 11/15/2025.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Bayview Rehabilitation and Healthcare Center in North Kingstown, RI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in North Kingstown, RI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Bayview Rehabilitation and Healthcare Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.