Based on record review, resident representative and staff interview, the facility failed to ensure that accurate and appropriate information was communicated to the receiving health care provider during an emergent discharge for Resident ID #1. When Resident ID #1 experienced a change in condition requiring emergency transfer to an acute care facility, Licensed Practical Nurse (LPN), Staff A, incorrectly identified the resident. As a result, Resident ID #1 was transferred with another resident's identifiers and medical record, placing Resident ID #1 at risk for delayed and/or inappropriate treatment.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 11/24/2025, alleges that Resident ID #1 was sent to the hospital on [DATE]… …
F628 citations in Rhode Island
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Rhode Island cites F628 less often than its own record predicts
0.37 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 F628.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Rhode Island surveyors wrote
F628 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 notify the Office of the State Long-Term Care Ombudsman, when a resident is hospitalized or discharged and return to the facility is not anticipated, for 2 out of 3 residents reviewed for facility discharges, Resident ID #s 117 and 119.Findings are as follows:1. Record review revealed Resident ID #117 was admitted to the facility in September of 2023. Additional review revealed s/he was transferred to and subsequently admitted to the hospital on [DATE].Review of the facility's March 2026 Ombudsman Notification Log failed to reveal evidence that Resident ID #117 was listed on the log.2. Record review revealed Resident ID #119 was admitted to the facility in March of 2026. …
Based on clinical record review and staff interview, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the transfer or discharge to the hospital for 2 of 2 residents reviewed for hospitalization, Resident ID #s 13 and 143. Findings are as follows:1. Record review revealed Resident ID #13 was discharged from the facility to the hospital on 5/13/2026 and on 5/23/2026. Additional review failed to reveal evidence that written notification was sent to the Office of the State Long-Term Care Ombudsman regarding either of the hospital transfers in May. 2. Record review revealed Resident ID #143 was discharged from the facility to the hospital on 5/20/2026. …
What else Rhode Island surveyors cite →
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