Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elderwood Of Scallop Shell At Wakefield during CMS and state inspections, most recent first.
A resident with pressure ulcers did not receive daily dressing changes as ordered by the physician. The Treatment Administration Record showed missed dressing changes on multiple dates. The resident confirmed the lapses, and an LPN acknowledged the oversight. Observations revealed soiled dressings, and the DON and Administrator could not explain the failure to follow orders.
The facility failed to document a resident's skin graft and did not conduct weekly skin assessments for two residents with known skin impairments. A resident with a new skin graft had no documentation of the wound's condition, while two other residents did not receive weekly skin assessments as required by the facility's policy. The DON acknowledged these deficiencies during a surveyor interview.
A resident with a history of fractures and anticoagulant use was prescribed 7500 units of heparin daily. However, due to a transcription error, the resident received only 5000 units daily for nearly two months. The error was identified during a survey, and the DON acknowledged the mistake.
The facility failed to maintain required hospice documentation for two residents receiving hospice care. Essential documents, such as the hospice plan of care and physician orders, were missing from the records. Interviews revealed that the facility did not have individual hospice binders, and the necessary documents were not available in the electronic medical records.
The facility did not implement Enhanced Barrier Precautions (EBP) for residents with wounds and an MDRO infection. Observations showed the absence of isolation carts or signage for three residents with wounds and one with an ESBL infection. Staff interviews confirmed the oversight, despite acknowledging the residents' conditions.
A resident with multiple pressure ulcers did not receive adequate care, as the facility failed to update wound vac therapy orders and document treatments. An LPN did not follow proper infection control protocols during wound care, risking cross-contamination. The facility also neglected to document weekly assessments of the ulcers, contrary to the care plan.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to meet professional standards of quality by not following physician's orders for wound care for a resident. The resident, who was admitted with pressure ulcers on the left hip, sacral region, and left buttock, had specific physician's orders for daily dressing changes using Medihoney and Allevyn foam dressings for the hip and sacrum, and Biostep with a bordered foam dressing for the buttock. However, the Treatment Administration Record for September 2024 showed that these dressings were not changed on several dates, specifically 9/9, 9/11, and 9/12. During interviews, the resident confirmed that the dressings were not changed daily as ordered. A Licensed Practical Nurse (LPN) acknowledged the oversight after reviewing the medical record. An observation by the surveyor confirmed that the dressings were dated 9/11 and were visibly soiled, indicating they had not been changed as required. The Director of Nursing Services and the Administrator were unable to provide an explanation or documentation of any refusal by the resident to have the dressings changed.
Failure to Document and Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive care plan. Specifically, Resident ID #24, who was admitted with heart failure and skin cancer, had a new skin graft on the left upper arm that required daily dressing changes. However, there was no documentation in the medical record regarding the skin graft, including details about the wound's condition, edges, and surrounding tissue, as required by regulation. The Director of Nursing Services acknowledged the lack of documentation during a surveyor interview. Additionally, the facility did not conduct weekly skin assessments for residents with known skin impairments, as per their policy. Resident ID #9, with type II diabetes mellitus and peripheral vascular disease, did not receive weekly skin assessments for five consecutive weeks, despite being at risk for skin impairment. A large fluid-filled blister was later discovered on the resident's left shin. Similarly, Resident ID #257, admitted with cellulitis and peripheral vascular disease, did not have weekly skin assessments for two weeks following the identification of blisters in the abdominal folds. The Director of Nursing Services confirmed the failure to follow the facility's policy and the residents' care plans regarding skin assessments.
Medication Error: Incorrect Heparin Dosage
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. The resident, who was admitted with multiple fractures and a long-term use of anticoagulants, had a hospital discharge order for heparin at a dosage of 7500 units daily. However, upon review, it was found that the order was inaccurately transcribed by the facility as 5000 units daily. This transcription error resulted in the resident receiving an incorrect dosage of heparin from the time of admission until the error was identified by a surveyor nearly two months later. The Director of Nursing Services acknowledged the transcription error during an interview with the surveyor.
Failure to Maintain Required Hospice Documentation
Penalty
Summary
The facility failed to ensure that hospice services met professional standards for two residents receiving hospice care. For one resident, admitted in December 2023 with Alzheimer's disease, the facility's records lacked essential hospice documentation, including the most recent hospice plan of care, hospice election form, physician certification and recertification of terminal illness, contact information for hospice personnel, instructions for accessing the hospice's 24-hour on-call system, hospice medication information, and physician orders. Similarly, another resident, admitted in April 2022 with diverticulosis, also had missing hospice documentation after starting hospice services in April 2024. Interviews with the facility's Administrator and Director of Nursing Services (DNS) revealed that the facility did not maintain individual hospice binders for each resident receiving hospice services. Instead, hospice documents were expected to be scanned into the electronic medical records. However, the DNS was unable to provide the required hospice documents for the two residents during the survey. The deficiency was identified when surveyors brought the issue to the facility's attention, prompting the facility to obtain and place the necessary hospice documents into the residents' charts.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for residents with wounds and a Multi-Drug Resistant Organism (MDRO) infection. Specifically, three residents with wounds and one resident with an Extended Spectrum Beta Lactamase (ESBL) infection were not placed on EBP, which involves using gowns and gloves during high-contact care activities. Surveyor observations from September 3 to September 6, 2024, revealed the absence of isolation carts or signage indicating the need for EBP outside the rooms of these residents. Resident ID #24 had a skin graft and required regular dressing changes, Resident ID #28 had multiple pressure ulcers, and Resident ID #267 had a diabetic foot ulcer, all of which necessitated EBP. Additionally, Resident ID #258, with a history of ESBL in the urine, was not placed on EBP until after the surveyor's intervention. Interviews with the Director of Nursing Services (DNS) and other staff confirmed the oversight, as they acknowledged the residents' conditions but failed to implement the necessary precautions.
Deficient Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care for a resident with multiple pressure ulcers, including a stage 3 ulcer on the right hip and a stage 4 ulcer on the sacral region. The resident was readmitted with a physician's order for wound vac therapy, which was not updated following a wound clinic appointment. The order lacked details on the type of foam dressing to be used, and the addition of adaptic to the tendon was not included in the updated orders, contrary to the recommendations from the wound clinic. During an observation, a Licensed Practical Nurse (LPN) was seen performing wound care without following proper infection control protocols. The LPN did not change gloves after removing a soiled dressing and proceeded to touch clean surfaces and apply a new dressing, which could potentially lead to cross-contamination. The resident was on contact precautions due to a positive MRSA test, emphasizing the need for strict adherence to infection control practices. The facility also failed to document the completion of wound treatments on several dates, as evidenced by blank entries in the Treatment Administration Record (TAR). There was no documentation of the treatments being completed or refused by the resident. Additionally, the facility did not follow its care plan for weekly assessment and documentation of the pressure ulcers, as there were no records of measurements or wound status for two weeks following an initial skin assessment.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 160 citations issued within 25 miles in the last 12 months — including the 13 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near South Kingstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Kingstown Nurs. & Rehab Ctr | 4.7 mi | — | 1 | 1 |
| South County Eden Operations Llc Dba Lakeside Nurs | 7.6 mi | — | 0 | 0 |
| Roberts Health Centre Inc | 8.9 mi | — | 1 | 0 |
| Village House Nursing & Rehabilitation Center | 9.3 mi | — | 6 | 0 |
| Kingston Center For Rehabilitation And Health Care | 10 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Elderwood Of Scallop Shell At Wakefield.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.