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
Meal tickets and the menu did not match the food actually served. Surveyors observed that a resident with intact cognition and several other residents did not receive items listed on their tickets, including soup, salad, pineapple, English muffins, and pudding. The FSD said soup was not offered during summer months per company policy, and the Dietitian should have updated the tickets; Staff F acknowledged the mismatch, and the DON said the discrepancies had been an ongoing concern.
Failure to Provide Written Notice for Room and Roommate Changes: The facility did not provide written notice, including the reason, before room or roommate changes for six residents. Residents with intact cognition, as well as residents with dementia or other cognitive impairment, and several resident representatives reported they were not notified in writing. The DON acknowledged the facility did not give written notification when room or roommate changes occurred.
A facility failed to complete ongoing reassessments of bed siderail safety for a resident with severe cognitive impairment and total dependence for bed mobility. The resident continued using the siderails for months without the required review, and later developed bruising and a traumatic posterior shoulder dislocation after the arm was reportedly caught in the rail. An internal investigation and later assessment found the siderails were unsafe and no longer indicated.
Failure to Report Suspicious Serious Injury: A resident with severe cognitive impairment and total dependence for bed mobility developed bruising to the arm and a traumatic shoulder dislocation after an unexplained incident. The injury was not witnessed, the resident could not explain it, and the Administrator acknowledged the event was suspicious, but there was no evidence it was reported to the proper authorities, including the State Survey Agency.
Failure to Thoroughly Investigate an Unexplained Injury: A resident with severe cognitive impairment and total dependence for bed mobility was found with bruising to the right armpit and posterior arm and later diagnosed in the ER with a closed traumatic posterior shoulder dislocation. Staff did not initiate a thorough investigation, no witnesses were identified, direct care staff were not interviewed for statements, and the facility's records did not show a complete investigation of the injury of unknown origin.
The facility failed to complete and document a comprehensive facility-wide assessment for resident care needs during routine operations and emergencies. The 2025 Facility Assessment was signed by former leadership, referenced a missing Staffing and Personnel Worksheet, listed prior admin and DON staff, and contained multiple sections stating no records were found. The facility also could not provide evidence of a plan to maximize recruitment and retention of direct care staff, and the DON acknowledged the assessment did not accurately reflect staffing patterns.
Meal tickets and menu items did not match served meals
Penalty
Summary
The facility failed to follow the weekly menu by not providing soup daily as listed on the menu for 4 of 4 units, and it also failed to ensure that residents’ meal tickets matched the meals actually served. During surveyor observation and resident interviews, Resident ID #93, who had diagnoses including type 2 diabetes mellitus and heart failure and had a BIMS score of 15 of 15, stated that meal tickets did not always match what was served and that soup was not provided even though the slips indicated soup every day. During lunch service on 6/30/2026, surveyors observed that Resident ID #12 did not receive soup and was served Jello instead of chocolate pudding, Resident ID #45 did not receive a side salad, and Residents ID #12, 20, 56, and 76 did not receive pineapple listed on their meal tickets. During breakfast service on 7/1/2026, surveyors observed that Residents ID #12, 20, 56, and 76 did not receive English muffins listed on their meal tickets. The Food Service Director stated that the facility does not offer soup during the summer months per company policy and that the Dietitian should have updated the residents’ meal tickets for accuracy. Staff F acknowledged that the meal tickets and food served on the nursing units did not match, and the DON stated that residents are expected to receive the items listed on the menu and that discrepancies between menu listings and meal tickets had been an ongoing concern.
Failure to Provide Written Notice for Room and Roommate Changes
Penalty
Summary
The facility failed to provide written notification, including the reason for a room change, before residents’ rooms or roommate assignments were changed for 6 of 6 residents reviewed. The facility policy titled Room Change stated that when a room change occurs, the resident being moved and the resident receiving a new roommate will be notified verbally and in writing, including the reason for the change, and that staff should complete a room change notice and place it in the medical record. Resident ID #45, admitted with type 2 diabetes and with a BIMS score of 15/15, was moved from the room on 4/1/2026, and the record did not show written notification of the room change or the reason for it. Resident ID #147, admitted with pneumonia and a BIMS score of 8/15, was moved to another floor on 6/9/2026; the record did not show written notification, and the resident stated s/he was not initially happy with the transfer because s/he had made friends on the second floor. Resident ID #66, admitted with anxiety and depression and with a BIMS score of 15/15, reported being awakened by staff and told the room would be changed, denied having a choice, and denied receiving written notice; the record also lacked evidence of written notification. Resident ID #93, with heart failure and a BIMS score of 15/15, stated s/he was not notified before receiving a roommate, and the record did not show written notice. Resident ID #99, with dementia and obsessive-compulsive disorder and a BIMS score of 0/15, had been moved three times between December 2024 and June 2026; the resident’s representative stated no written notifications were provided, and the record lacked evidence of written notice. Resident ID #101, with dementia and a BIMS score of 0/15, had been moved three times between January 2026 and June 2026; the representative also stated no written notifications were provided, and the record lacked evidence of written notice. The Social Worker stated that the facility completes an assessment in the record when a room change or roommate change occurs but does not give written notification to the resident or resident representative, and the DON acknowledged the facility failed to provide the required written notification for all six residents.
Failure to Reassess Bed Siderail Safety Led to Resident Injury
Penalty
Summary
The facility failed to ensure the correct use and ongoing reassessment of bed siderails for one resident who had severely impaired cognition and was totally dependent on staff for bed mobility. The resident was admitted with diagnoses including Alzheimer's disease and polyosteoarthritis, and a Quarterly MDS assessment showed a BIMS score of 4 out of 15, indicating severely impaired cognition. The record showed that the resident continued to use bed siderails, but the facility did not document the required reassessments of the continued need for and safety of the siderails for approximately 15 months after the last reassessment. After the resident was found with bruising to the right armpit and right posterior arm, the resident was transferred to the Emergency Department and diagnosed with a closed traumatic posterior dislocation of the right shoulder. Because of the resident's cognitive impairment, the resident could not recall how the injuries occurred. In the facility's internal investigation, the former DNS stated that the bruise appeared shaped like the side rail, with striations matching the bars on the rail, and that the resident slept on the right side with the arm around the side rail. The statement indicated the arm likely became caught in the siderail and the shoulder was dislocated when the resident tried to pull it out. The facility's records did not show evidence that the required ongoing reassessments were completed after 2/4/2025 to determine whether the bed siderails remained clinically appropriate and safe. During surveyor interview, the Administrator, with the current DNS present, was unable to provide evidence of the required reassessments. A bed siderail assessment completed after the injury determined that the siderails were unsafe for the resident's continued use and were not indicated because they created an accident hazard.
Failure to Report Suspicious Serious Injury
Penalty
Summary
The facility failed to ensure that an allegation involving an accident resulting in serious injury was reported to the appropriate authorities, including the State Survey Agency, as required by State law. The deficiency involved one resident who was admitted with diagnoses including Alzheimer's disease and polyosteoarthritis, and whose quarterly MDS showed a BIMS score of 4 out of 15, indicating severely impaired cognition, with total dependence on staff for bed mobility. A nursing note documented that a nursing assistant reported bruising to the resident's right armpit and right posterior arm, and the resident could not recall how the bruising occurred because of cognitive impairment. The resident was sent to the ER and returned with a sling on the right arm, and hospital records showed a closed traumatic right posterior shoulder dislocation. The facility's internal investigation stated the bruise appeared shaped like the side rail of the bed and suggested the resident's arm may have become caught in the side rail, resulting in the shoulder dislocation when the resident tried to pull it out. During interview, the Administrator acknowledged the injury was not observed by any person, could not be explained by the resident, and was suspicious due to the location and type of injury, but he could not provide evidence that the incident had been reported to the appropriate authorities.
Failure to Thoroughly Investigate an Unexplained Bruise and Shoulder Dislocation
Penalty
Summary
The facility failed to ensure that an injury of unknown origin was thoroughly investigated for a resident admitted in January 2025 with diagnoses including Alzheimer's disease and polyosteoarthritis. The resident's Quarterly MDS showed a BIMS score of 4 out of 15, indicating severely impaired cognition, and the resident was totally dependent on staff for bed mobility. A nursing progress note documented that a nursing assistant reported bruising to the resident's right armpit and right posterior arm, and the resident was unable to explain how the bruising occurred. Staff interviews and record review showed that no complete investigation was initiated or documented after the bruising was discovered. One RN stated she did not identify any witnesses, knew the resident lacked the cognitive ability to report the cause, and did not initiate an investigation. Another RN stated the bruising was not present on one shift but was noted on the next, yet she also did not initiate an investigation, and management did not interview or obtain a statement from her. The resident was later sent to the ER and diagnosed with a closed traumatic right posterior dislocation of the shoulder joint. The internal investigation documents provided did not show a complete investigation, and the Administrator acknowledged the injury was unobserved, unexplained by the resident, suspicious due to its location and type, and that the facility could not provide evidence of a thorough investigation.
Facility Assessment Not Updated to Reflect Staffing Needs
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine what resources were necessary to care for residents competently during day-to-day operations, including nights and weekends, and during emergencies. Review of a community-reported complaint alleged a severe and persistent staffing shortage at the facility. Review of the 2025 Facility Assessment showed it was signed by the former administrator and former DNS on 3/30/2026, and it referenced a Staffing and Personnel Worksheet that was not found in the attachments. Multiple supporting document sections stated, "No records were found." The assessment also listed previous employees as the administrator and DNS rather than the current administrator and DNS. The facility also failed to provide evidence of a plan to maximize recruitment and retention of direct care staff. During interview, the DNS acknowledged that the Facility Assessment did not accurately reflect the staffing patterns of the facility and could not provide evidence of a recruitment and retention plan for direct care staff.
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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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