Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to honor a resident's right to refuse treatment, for 1 of 1 resident reviewed, Resident ID #39. Findings are as follows: Review of a community reported complaint received by the Rhode Island Department of Health on 8/19/2024 alleges that Resident ID #39 received a medication for 3 days, without his/her consent. Record review revealed the resident was admitted to the facility in June of 2023 with diagnoses including, but not limited to, cervical disc degeneration, morbid obesity, and hypertensive kidney disease. Review of a Brief Interview for Mental Status Assessment completed on 6/5/2024 revealed a score of 15 out of 15, indicating s/he is cognitively intact. …
F578 citations in Rhode Island
Advance directives · Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Rhode Island cites F578 less often than its own record predicts
0.55 times the national share — cited less often here than elsewhere.
Of every deficiency written in Rhode Island in 2025, this is the portion that was F578.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Rhode Island surveyors wrote
F578 findings written in Rhode Island, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on clinical record review and staff interview, the facility failed to ensure that the resident's formulated advance directive would be followed due to inconsistency between the signed advanced directive and the electronic medical record (EMR) for 1 of 1 resident reviewed for a change in code status, Resident ID #86.Findings are as follows:Record review revealed a signed Advanced Directive dated 4/27/2026, indicating that the resident checked Full Code, .911 will be called. All resuscitative and aggressive measure are provided and I will be transferred to the hospital.Record review revealed a physician's order for Do Not Resuscitate (DNR) with a start date of 5/27/2025. …
Based on clinical record review, and staff interviews, it has been determined the facility failed to ensure that a current copy of a residents advance directive was in the resident's medical records, for 11 of 14 sample residents (ID #'s 2,5,9,13,18,19,21,26,27,30 & 131). Findings are as follows: Review of the records for resident's IS #'s 2,5,9,13,18,19,21,26,27,30, &131 revealed that they lacked evidence of an advance directive. During surveyor interview with Staff Nurse A on 11/29/2018 at approximately 10:15 AM, when questioned about advance directives, she informed the surveyor that the facility has a Medical Orders for Life Sustaining Treatment (MOLST) form which they use but does not have any other form. …
The short window
Recent years
| Year | Share of Rhode Island citations | vs expected |
|---|---|---|
| 2023 | 0.57% | 0.53× |
| 2024 | 0.59% | 0.60× |
| 2025 | 0.52% | 0.55× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Rhode Island surveyors cite →
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