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Statistics for Rhode Island (Last 12 Months)

75
Total Providers
228
Total Inspections in the last 12 months
Information
This includes all types of inspections: standard annual surveys, life safety code surveys, re-surveys, complaint investigations, and follow-up inspections.
88%
Providers with Citations in the last 12 months
Information
Among all providers that received one or more inspections in the last 12 months, this represents the percentage that received at least one citation of any severity level.
21.3%
Providers with Serious Citations in the last 12 months

Financial Impact (Last 12 Months)

$183,420
Maximum Single Fine
$25,847
Median Fine
20
Max Payment Suspension Days
5
Median Suspension Days

Some of the Latest Corrective Actions taken by Facilities in Rhode Island


Latest Citations in Rhode Island

Where do we get this info
Information
Our data comes from the CMS latest release (July 30, 2025) and state websites, both sourced from public records.
Abrupt Discontinuation of Clonazepam Results in Significant Medication Error
D
F0760
Short Summary

A resident with a history of anxiety and mood disorders experienced a significant medication error when clonazepam was abruptly discontinued for several days during a gradual dose reduction process. The resident did not receive the medication as ordered, leading to increased anxiety and hand tremors. Facility staff and providers failed to ensure proper communication and follow-up regarding the medication changes, resulting in the resident not being free from significant medication errors.

No penalty information released
tooltip icon
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Failure to Administer Pain Medications per Physician Orders
D
F0658
Short Summary

A resident with recent spinal surgery did not receive prescribed pain medications as ordered. The Buprenorphine patch was not available and was falsely documented as administered, while Dilaudid was given at half the prescribed dose on two occasions. Staff interviews and record reviews confirmed these discrepancies, and the DON acknowledged the failure to follow physician orders.

No penalty information released
tooltip icon
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Failure to Timely Report Alleged Abuse to State Agency
D
F0609
Short Summary

A resident with dementia and anxiety disorder, who was cognitively intact, threatened to physically harm another resident and was sent to the ER for evaluation. The DON acknowledged that this incident, which met the criteria for abuse reporting, was not reported to RIDOH as required by state law and facility policy.

No penalty information released
tooltip icon
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Failure to Properly Store and Label Medications
D
F0761
Short Summary

Surveyors found that medications, including Trelegy Ellipta inhalers, Morphine Sulfate, and Lorazepam Intensol, were opened and not dated, and that Lorazepam was not refrigerated as required. Staff acknowledged these lapses in medication storage and labeling during interviews.

No penalty information released
tooltip icon
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Failure to Follow Bowel Protocol and Provide Timely Interventions for Constipation
D
F0684
Short Summary

Three residents with conditions such as hemiplegia, Alzheimer's disease, and cognitive impairment did not receive timely bowel interventions or GI assessments as required by facility protocol when experiencing multiple days without adequate bowel movements. Prescribed medications and interventions were not consistently administered, and providers were not notified of refusals or lack of results, as confirmed by staff interviews.

No penalty information released
tooltip icon
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Resident Injury Due to Improper Use of Shower Chair on Incline
G
F0689
Short Summary

A resident who required two-person assistance for transfers sustained fractured ribs after a nursing assistant attempted to pull the resident backwards in a shower chair up a steep incline into a shower stall. The chair tipped and broke, causing the resident to fall and require hospital admission. The incident occurred despite manufacturer warnings against using the chair on an incline and the resident's care plan specifying the need for two staff during transfers.

No penalty information released
tooltip icon
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Failure to Adhere to Medication Administration Standards and Documentation
D
F0658
Short Summary

Nursing staff administered a controlled medication prescribed for one resident to another hospice resident due to a pharmacy backorder, in violation of facility policy. The transfer and administration of the medication were inaccurately documented in the narcotic count book, and the physician's order was entered with the incorrect route. Staff acknowledged the errors in both medication handling and documentation.

No penalty information released
tooltip icon
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Failure to Document and Complete Physician-Ordered Skin Assessments
D
F0658
Short Summary

Two residents with complex medical conditions did not have required weekly skin assessments documented, despite physician orders and MAR sign-offs indicating completion. The DON was unable to provide evidence that these assessments were performed or recorded as required.

No penalty information released
tooltip icon
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Failure to Develop Baseline Care Plan for Surgical Wound and Hemovac Drain
D
F0655
Short Summary

A resident admitted after spinal surgery with a Hemovac drain and surgical wound did not have a baseline care plan developed within 48 hours that addressed care instructions for the wound or drain. Nursing leadership confirmed the omission when interviewed, and the resident was later hospitalized after presenting with signs of infection.

No penalty information released
tooltip icon
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Failure to Monitor and Document Hemovac Drain Output per Professional Standards
D
F0658
Short Summary

A resident with a Hemovac drain following spinal surgery did not have their drain output monitored or documented as required by facility policy. There were no physician orders for drain management, and staff could not provide evidence of required monitoring or documentation. This failure was confirmed by interviews with nursing staff, the DON, and the facility physician, as well as by the lack of documentation provided to the surgeon's office.

No penalty information released
tooltip icon
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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