Cycle 1
Health 2025-02-12 · Fire 2025-02-12
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
West Kingston, RI
South Kingstown Nurs. & Rehab Ctr
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2115 South County Trail, West Kingston, RI
(401) 783-8568
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
98
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Health Concepts, Ltd.
Operator or chain grouping
Approved since
1978-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 4 overall / 4 health / 3 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.60
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.52
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.46 · national 2.35
Total nurse hours
3.52
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.12
RN + LPN hours · state 1.25 · national 1.54
Weekend hours
3.15
Weekend nurse staffing · state 3.30 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
3.81
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 38% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,494
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9855
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.51
Baseline 19.48% · Performance 20.73% · Measure score 1.51 · Achievement 1.51 · Improvement 0
Healthcare-associated infections
4.80
Baseline 5.55% · Performance 6.40% · Measure score 4.80 · Achievement 4.80 · Improvement 0
Total nurse turnover
4.2
Baseline 52.00% · Performance 46.51% · Measure score 4.2 · Achievement 4.2 · Improvement 1.52
Adjusted total nurse staffing
1.33
Baseline 3.96 hours · Performance 3.45 hours · Measure score 1.33 · Achievement 1.33 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.57% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 142 · Observed rate 8.45% · Lower 95% interval 6.88% |
| Discharge to community | 54.9% |
50.57%
4.3 pts better
|
No Different than the National Rate · Eligible stays 134 · Observed rate 55.97% · Lower 95% interval 48.17% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 93.41% |
95.27%
1.9 pts worse
|
Numerator 85 · Denominator 91 |
| Falls with major injury | 2.2% |
0.77%
1.4 pts worse
|
Numerator 2 · Denominator 91 |
| Discharge self-care score | 50.68% |
53.69%
3 pts worse
|
Numerator 37 · Denominator 73 |
| Discharge mobility score | 52.05% |
50.94%
1.1 pts better
|
Numerator 38 · Denominator 73 |
| Pressure ulcers or injuries, new or worsened | 3.3% |
2.29%
1 pts worse
|
Numerator 3 · Denominator 91 · Adjusted rate 3.8% |
| Healthcare-associated infections requiring hospitalization | 6.4% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 4.12% · Lower 95% interval 3.6% |
| Staff COVID-19 vaccination coverage | 25.9% |
8.2%
17.7 pts better
|
Numerator 36 · Denominator 139 |
| Staff flu vaccination coverage | 58.21% |
42%
16.2 pts better
|
Numerator 78 · Denominator 134 |
| Discharge function score | 52.05% |
56.45%
4.4 pts worse
|
Numerator 38 · Denominator 73 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.74% |
96.28%
0.5 pts worse
|
Numerator 45 · Denominator 47 |
| Resident COVID-19 vaccinations up to date | 37.21% |
25.2%
12 pts better
|
Numerator 16 · Denominator 43 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.5
0.2 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.7
0.9 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.1% |
93.2%
3.1 pts worse
|
93.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.5% · Q2 95.1% · Q3 93.0% · Q4 82.1% · 4Q avg 90.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.6% |
95.3%
0.3 pts better
|
95.5%
0.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.6%
0.9 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 4.9% · Q3 3.5% · Q4 3.6% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.0% |
14.6%
10.6 pts better
|
11.4%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 7.5% · Q3 1.4% · Q4 1.6% · 4Q avg 4.0% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
5.3%
0.3 pts better
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 8.8% · Q3 1.4% · Q4 4.3% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.5% |
16.4%
6.9 pts better
|
19.6%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 7.1% · Q3 7.2% · Q4 12.9% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.8% |
23.6%
5.8 pts better
|
16.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 15.8% · Q3 16.4% · Q4 23.3% · 4Q avg 17.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.9% |
17.0%
10.9 pts worse
|
16.3%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.5% · Q2 25.7% · Q3 18.4% · Q4 30.2% · 4Q avg 27.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 33.1% |
18.4%
14.7 pts worse
|
14.9%
18.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.9% · Q2 29.2% · Q3 16.9% · Q4 40.3% · 4Q avg 33.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.0%
0.5 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
2.2%
1.1 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.5% · Q3 4.7% · Q4 2.4% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.1% |
22.3%
6.8 pts worse
|
19.8%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 26.6% · Q3 26.5% · Q4 34.5% · 4Q avg 29.1% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
4.7%
1 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 1.2% · Q3 3.1% · Q4 5.3% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.8% |
77.2%
8.4 pts worse
|
81.7%
12.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 69.1% · Q2 71.8% · Q3 70.5% · Q4 64.1% · 4Q avg 68.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.2% |
15.8%
9.4 pts worse
|
12.0%
13.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.2% · Observed 24.7% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.0% |
1.9%
2.1 pts worse
|
1.6%
2.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 4.1% · Q3 4.2% · Q4 5.0% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.1% |
78.2%
4.9 pts better
|
79.7%
3.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.2% |
25.1%
2.1 pts worse
|
23.9%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.2% · Observed 26.0% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-28 · Fire 2024-02-28
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-12-08 · Fire 2022-12-08
3 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-03
E · Potential for more than minimal harm
2024-02-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-15
F · Potential for more than minimal harm
2022-12-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-18
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-05-17
D · Potential for more than minimal harm
2025-04-18
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-17
E · Potential for more than minimal harm
2025-02-12
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-03-03
E · Potential for more than minimal harm
2025-02-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-03
D · Potential for more than minimal harm
2024-09-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-02-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-15
D · Potential for more than minimal harm
2022-12-08
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-01-07
D · Potential for more than minimal harm
2022-12-08
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Not marked corrected
D · Potential for more than minimal harm
2022-12-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-07
Penalties and ownership
What sits behind the stars
Ownership
Ryan, David
5% Or Greater Direct Ownership Interest · Individual
Ryan, Sally
5% Or Greater Direct Ownership Interest · Individual
Arnold, Kelly
W-2 Managing Employee · Individual
Carragher, Terry
Corporate Director · Individual
Health Concepts Ltd
Operational/Managerial Control · Organization
Mcguninness, Brian
W-2 Managing Employee · Individual
Pringle, Kishma
W-2 Managing Employee · Individual
Ryan, David
Corporate Director · Individual
Ryan, Sally
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Elderwood Of Scallop Shell at Wakefield
South Kingstown, RI
2-star overall rating with 2-star inspections with $70,499 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Kingston Center For Rehabilitation And Health Care
West Kingston, RI
4-star overall rating with 5-star inspections
#3
South County Nursing and Rehabilitation
North Kingstown, RI
4-star overall rating with 4-star inspections with $14,433 in total fines with 4 recent health deficiencies
Jump out