Based on record review and staff interview, it has been determined that the facility failed to implement care plan interventions to monitor a resident with a known history of wandering and exit seeking, which resulted in the resident leaving the building unsupervised, putting the resident at risk for serious injury or death., for 1 of 1 residents reviewed who successfully eloped from the facility, Resident ID #1. Findings are as follows: Record review of a facility policy titled, POLICY AND PROCEDURE Elopement Assessments states in part, POLICY: It is the policy of this facility to maintain a safe and secure environment for all of our residents. In order to achieve this; residents who are at risk for wandering/elopement need to be identified and a care plan developed to eliminate the risk. …
F656 citations in Rhode Island
Comprehensive care plan · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Rhode Island cites F656 less often than its own record predicts
0.45 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 F656.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Rhode Island surveyors wrote
F656 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 record review and staff interview, it has been determined that the facility failed to create and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 3 residents reviewed for refusal of care and medication non-compliance, Resident ID #1. Record review of a facility reported incident submitted to the Rhode Island Department of Health on 4/10/2023 states in part, Resident was found on floor in [his/her] room .Blood sugar read high on glucometer [a device used to measure a persons blood glucose. A high reading is indicative of a blood sugar that typically exceeds 600 milligrams(mg) per deciliter]. …
Based on record review and staff interview, the facility failed to provide care in accordance with a resident's plan of care for 3 of 3 resident's relative to turning and repositioning, Resident ID #s 1, 2, and 4.Findings are as follows:1) Record review revealed that Resident ID #1 was readmitted to the facility in March of 2026 with diagnoses including, but not limited to, Parkinson's disease (a progressive neurological disease that primarily affects movement) and adult failure to thrive.Record review of a care plan dated 12/19/2025 revealed in part, .The resident has a pressure ulcer or has the potential for pressure ulcer development. …
The short window
Recent years
| Year | Share of Rhode Island citations | vs expected |
|---|---|---|
| 2023 | 1.52% | 0.42× |
| 2024 | 1.92% | 0.56× |
| 2025 | 1.56% | 0.45× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Rhode Island surveyors cite →
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