Citations in Rhode Island
Statistics, citations and compliance trends for long-term care facilities in Rhode Island.
Statistics for Rhode Island (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Rhode Island
Failure to provide ordered PT services for a resident with TBI and severe cognitive impairment. The resident had repeated specialist recommendations for PT, OT, and ST, including ROM and therapy at max allotted intervals, but the record showed no PT screen, eval, or treatment for more than 6 months after the request was approved by the PA. The Rehab Director acknowledged the resident had not received PT since the prior year, and the Administrator and DON could not provide evidence of the ordered rehab services.
Failure to Protect Residents from Resident-to-Resident Abuse: Two residents were involved in a verbal confrontation in which one resident threatened to kill the other and became aggressive while trying to get closer to the other resident. In a separate incident, another resident was observed in a resident’s room with a hand under the bed sheets touching the resident inappropriately while the resident was in a hospital gown without underwear or a brief.
A resident with colitis and renal dialysis dependence did not receive ordered hydrocortisone enemas after hospital discharge because the medication was not available, and MAR review showed multiple missed doses. The resident reported worsening rectal pain, appeared pale and weak, and was later rehospitalized after hospital records noted a relapse of symptoms that improved once the steroid enemas were started. The facility also missed ordered Veltassa doses after a later discharge despite a critically elevated K+ level, and staff acknowledged the medication was not administered because it had not been delivered by the pharmacy.
A resident with chronic pain and respiratory failure received 10 times the ordered Morphine dose after a new concentrated formulation was dispensed and administered without proper reconciliation or transcription into the MAR. Facility nurses did not promptly notify the provider, and the NP who changed the order did not directly communicate the discontinuation of the prior Morphine order to the facility. The report also cites a deficiency involving insulin use for another resident.
A resident with dementia and osteoarthritis had an order for Morphine Sulfate solution, but MAR review showed it was not administered. Surveyors found the opened narcotic bottle was missing 1 mL without documentation of administration, and staff reported the discrepancy was adjusted in the narcotic count after an LPN noticed the bottle had been opened. The Unit Manager did not notify the Administrator or DON, and the DNS said the concern was not brought to her attention until surveyors identified it.
A resident with dysphagia, protein-calorie malnutrition, ESRD, and a feeding tube did not receive multiple ordered bolus Nepro feedings as scheduled. The MAR lacked documentation for several prescribed feedings, the resident reported staff were not consistently giving the tube feedings and sometimes missed them entirely, and the dietitian and DON could not provide evidence that the ordered feedings were administered.
Failure to Provide Ordered PT Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services for one resident with a history of traumatic brain injury. The resident was admitted in December 2024 and had a Quarterly MDS showing a BIMS score of 4 of 15, indicating severe cognitive impairment, with dependence on staff for bed mobility and transfers. A Continuity of Care Consultation and Referral Form from a university medicine and rehabilitation provider dated 1/27/2026 recommended resuming PT and OT, and a nursing progress note the same day showed the recommendation was reviewed and approved by a PA. Additional consultation forms dated 3/31/2026, 5/21/2026, and 6/30/2026 continued to recommend PT, OT, and ST, including ROM to the bilateral upper and lower extremities and therapy at the maximum allotted intervals at the facility. Record review did not reveal evidence of a PT screen, evaluation, or treatment after the January 2026 request, and the resident had gone more than 6 months without the recommended rehabilitative services. A PM&R physician note dated 6/30/2026 stated that PT/OT/ST were strongly recommended at the maximum allocated intervals due to ongoing functional gains. During interviews, the PA stated she approved the therapy recommendations and expected staff to follow specialist recommendations. The Rehab Director acknowledged the resident had not been evaluated or treated by PT since December 2025 and knew PT had been requested several times since January 2026. The Administrator and DON were unable to provide evidence that the resident received the specialized rehabilitation services after approval.
Failure to Protect Residents from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident abuse for two residents. In one incident, Resident ID #1 and Resident ID #2 were involved in a verbal altercation witnessed by staff, during which Resident ID #2 was overheard saying, "I will make sure you die overnight." Staff statements in the facility’s internal investigation also indicated that Resident ID #2 made threatening comments and became aggressive with staff while trying to get physically closer to Resident ID #1. Resident ID #1 had diagnoses including major depressive disorder, cognitive communication deficit, and opioid dependence, and a BIMS score of 15 of 15. Resident ID #2 had diagnoses including bipolar II disorder, hemiplegia, hemiparesis following a stroke, and migraines, and also had a BIMS score of 15 of 15. Resident ID #1 later told the surveyor that Resident ID #2 attempted to physically attack him/her after threatening to kill him/her. In a separate incident, Resident ID #4 was observed in Resident ID #3’s room with a hand under the bed sheet. Staff A stated that Resident ID #4 had been repeatedly passing by Resident ID #3’s room and then, while assisting another resident, saw Resident ID #4’s reflection in a window and observed him/her touching Resident ID #3 inappropriately under the bed sheets. Staff A reported that Resident ID #3 was in a hospital gown without underwear or a brief on at the time. Resident ID #3 had diagnoses including acquired absence of the eye, purulent endophthalmitis, schizoaffective disorder, muscle weakness, and opioid use, with a BIMS score of 14 of 15. Resident ID #4 had diagnoses including bilateral below-the-knee amputations and anxiety, with a BIMS score of 14 of 15.
Failure to Administer Ordered Medications After Hospital Discharge
Penalty
Summary
The facility failed to ensure physician’s orders were implemented for a resident who was cognitively intact and had diagnoses including noninfective gastroenteritis, colitis, and dependence on renal dialysis. After a hospital discharge, the resident returned with an order for Hydrocortisone 100 mg/60 mL enema twice daily for 18 days, but the July 2026 MAR did not show administration of the enema on the PM dose of 7/10, both doses on 7/11 and 7/12, or the AM dose on 7/13. A nursing progress note on 7/11 stated the enema would not be delivered until 7/13. During this period, the resident reported repeated moderate to severe rectal pain, including pain scores of 6, 5, 8, 8, 7, and 6 on multiple dates and times. Nursing notes documented that the resident appeared pale, weak, and fatigued while the enemas had still not been delivered, and later complained that pain medication was not working. The resident requested transfer to the hospital because of severe pain, and hospital documentation stated the resident had persistent pain and fever and experienced a relapse in symptoms after missing several hydrocortisone enemas; the symptoms resolved once the steroid enemas were started. The facility also failed to administer Veltassa after a later hospital discharge. Hospital documentation showed the resident had a critically elevated potassium level of 6.1 on 7/16/2026, with a repeat level of 5.7, and discharge paperwork ordered Veltassa 8.4 grams daily. The July 2026 MAR did not show the medication was given on 7/19 or 7/20. The resident stated the medication had not been received because it had not been delivered by the pharmacy, and a CMT acknowledged she did not administer it because it was not available and documented a code indicating the facility was waiting for pharmacy delivery. The DON stated she was unaware the resident had missed the Veltassa doses until the surveyor brought it to her attention, and the NP stated she had not been notified that the hydrocortisone enemas were missed or that Veltassa had not been given.
Significant medication errors with Morphine Sulfate and insulin
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors involving Morphine Sulfate and insulin use. One resident with diagnoses including acute and chronic respiratory failure and chronic pain disorder, and with intact cognition, had a physician’s order for Morphine Sulfate 10 mg/5 mL, 2.5 mL (5 mg) by mouth every six hours as needed for pain. A Pyxis transaction showed that Morphine Sulfate 100 mg/5 mL was dispensed, which was 10 times more potent than the ordered concentration. The resident’s MAR did not show the new prescription being transcribed, and the narcotic administration book documented that 2.5 mL of the 100 mg/5 mL solution was administered, resulting in a 50 mg dose, 10 times the prescribed amount. The narcotic administration book also lacked documentation of the directions for administration, dosage, route, date received, and date opened. The provider was not notified of the medication error until more than 24 hours after the overdose occurred. The resident stated that he or she was not told about the error until the facility was sending him or her to the hospital and described sitting in a wheelchair rocking and nodding off after the overdose. Staff interviews showed that the charge nurses and the nurse who identified the discrepancy did not notify the provider promptly, and one nurse administered the concentrated Morphine without reconciling it against an active physician’s order in the electronic record. The Optum NP who issued the new Morphine prescription stated that she changed the concentration to Morphine Sulfate concentrate 100 mg/5 mL but did not notify the facility that the prior order had been discontinued and replaced. She communicated only with the Optum RN, not directly with the facility nurse, and later believed the overdose had just occurred that day. The Optum RN, the facility nurses, and the NP all described delays and breakdowns in communication regarding the medication change and the overdose. The report also states that the deficiency involved 1 of 3 residents reviewed for Morphine Sulfate and 1 of 2 residents reviewed for insulin use.
Misappropriation Concern Involving Controlled Medication
Penalty
Summary
The facility failed to ensure a resident was free from misappropriation of property involving an opened Morphine Sulfate solution bottle that was found to be missing 1 mL of medication without documentation that it had been administered to the prescribed resident. Resident ID #6 was admitted with diagnoses including dementia and osteoarthritis, and had a physician’s order for Morphine Sulfate solution 20 mg per 1 mL, 0.25 mL by mouth every four hours as needed for pain. Review of the MARs for May, June, and July 2026 showed the medication had not been administered to the resident. The narcotic book showed 15 mL of Morphine Sulfate solution was received from the pharmacy, then later adjusted to 14 mL after two LPNs signed as witnesses. No documentation was found showing when the bottle had been opened. During surveyor observation, the bottle was open and appeared to contain approximately 14 mL. An LPN stated the bottle had been sealed when delivered, later noticed it was opened during a narcotic count, and reported that the medication had not been administered to the resident. The Unit Manager was notified but did not inform the Administrator or DNS, and the DNS stated she had not been made aware of the potential misappropriation until the surveyor raised the concern.
Missed Physician-Ordered Tube Feedings
Penalty
Summary
The facility failed to administer physician-ordered bolus tube feedings as prescribed for a resident who required enteral nutrition via feeding tube. The resident was admitted in May 2026 with diagnoses including dysphagia following a stroke, protein calorie malnutrition, and end stage renal disease, and the admission MDS indicated a BIMS score of 12 out of 15 with moderately impaired cognition. The resident also received dialysis in the facility three times per week. During interview, the resident stated that nursing staff had not consistently given the tube feedings as ordered, that the resident sometimes had to notify staff when the feeding was overdue, and that there were occasions when the feedings were not given at all. Record review showed multiple physician orders for Nepro bolus feedings at scheduled times throughout June and July 2026, with several order changes over that period. The MAR did not show the resident received the prescribed tube feedings on multiple dates and times, including missed feedings at 1:00 PM, 7:00 PM, and 10:00 PM on 6/3/2026; 7:00 PM and 10:00 PM on 6/15/2026; 7:00 PM on 6/18/2026; 1:00 PM on 6/19/2026; 10:00 PM on 6/20/2026; 1:00 PM and 7:00 PM on 6/22/2026; 9:00 AM and 1:00 PM on 6/23/2026; and 10:00 PM on 7/7/2026. The dietitian stated she was not aware the tube feedings had not been given until the surveyor brought it to her attention, the DON could not provide evidence that the feedings were administered as ordered, and the physician stated he expected the resident to receive the tube feedings as ordered.
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Compliance trends in Rhode Island
Data through Jun 2026Comparisons below measure the most recent period Jul 2025 – Jun 2026 against the prior period Jul 2024 – Jun 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
No tags meet the emerging criteria for this period — nothing rare is spiking right now.
Trusted data from CMS and state health departments
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