Based on record review and staff interview, the facility failed to accurately report to the State Agency, an incident including the full details and circumstances surrounding the death of a resident, who was observed by staff deceased , with his/her head and neck between the mattress and the bed rail. Additionally, the former Administrator who also observed the resident in this manner, omitted these details when reporting the incident involving Resident ID #1. Findings are as follows:Record review of a facility reported incident initially submitted to the Rhode Island Department of Health (RIDOH) by the former facility Administrator on [DATE], revealed that on the morning of [DATE] at approximately 6:40 AM Resident ID #1 was found deceased , in a sitting position on the floor. …
F609 citations in Rhode Island
Reporting alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Rhode Island cites F609 less often than its own record predicts
0.14 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 F609.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Rhode Island surveyors wrote
F609 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.
The short window
Recent years
| Year | Share of Rhode Island citations | vs expected |
|---|---|---|
| 2023 | 0.76% | 0.38× |
| 2024 | 1.04% | 0.45× |
| 2025 | 0.35% | 0.14× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Rhode Island surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction