Based on surveyor record review and staff interview, it has been determined that the facility failed to ensure that the assessment accurately reflected the resident's status for 1 of 6 residents reviewed for pressure ulcers for sample resident ID #329. Findings are as follows: Record review for resident ID #329, reveals the resident was admitted to the facility on [DATE]. Review of the record reveals multiple inaccurate skin assessments on the 6/13 and 6/114/2018. Review of the Admission Skin Assessment Form by nurse Staff A, dated 6/13/2018, revealed that the resident had a stage 1 pressure ulcer to the coccyx. Review of the Skin Ulcer Documentation by nurse Staff B, dated 6/13/2018, revealed the resident had a stage 1 pressure ulcer and describes it as an open area to coccyx. …
F641 citations in Rhode Island
Accuracy of assessments · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Rhode Island cites F641 less often than its own record predicts
0.47 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 F641.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Rhode Island surveyors wrote
F641 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 assessments accurately reflect the resident's status for 1 of 3 residents reviewed related to pressure ulcers (an area of localized damage to the skin and/or underlying tissue that develops as a result of prolonged pressure), Resident ID #2.Findings are as follows:Record review revealed the resident was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, quadriplegia (paralysis that affects all four limbs and the body from the neck down).Record review of a document titled Skin Issues dated 3/5/2026 revealed that the resident had a Stage 2 pressure ulcer (is a partial -thickness loss of the skin where the dermis is exposed, forming a shallow, red or pink wound or… …
Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that the assessment accurately reflected the resident's status for 1 of 1 resident reviewed for hand contractures (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff), Resident ID #23. Findings are as follows: Record review revealed the resident was admitted to the facility in January of 2022 with diagnoses including, but not limited to, age-related physical disability, tremors, and contracture of the right hand. …
The short window
Recent years
| Year | Share of Rhode Island citations | vs expected |
|---|---|---|
| 2023 | 1.14% | 0.67× |
| 2024 | 1.04% | 0.61× |
| 2025 | 0.87% | 0.47× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Rhode Island surveyors cite →
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