F658 in Rhode Island. Pick another state for the same tag.
Against expectation — 2025
Rhode Island cites F658 more often than its own record predicts
Versus expected share6.12×
6.12 times the share F658 takes of citations nationally.
Share of Rhode Island citations10.92%
Of every deficiency written in Rhode Island in 2025, this is the portion that was F658.
Rhode Island10.92%
National1.78%
Share of all citations that were F658.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Rhode Island surveyors wrote
F658 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.
J · Immediate jeopardy, isolatedMay 5, 2026
Based on clinical record review, and staff interview, the facility failed to ensure care and services were provided in accordance with professional standards of clinical practice for 1 of 3 residents reviewed receiving insulin therapy for diabetes mellitus, Resident ID #1. Specifically, the facility failed to ensure a complete and clinically appropriate insulin order was obtained, accurately transcribed, and safely administered, resulting in the resident receiving rapid-acting insulin during overnight hours without meal intake, causing severe hypoglycemia requiring emergent hospital transfer. …
Based on clinical record review and staff interviews, the facility failed to ensure that care and services provided to 1 of 2 residents related to anticoagulation therapy, Resident ID #1, were in accordance with accepted professional standards of practice. Specifically, multiple staff members failed to appropriately question, clarify, verify, and communicate concerns regarding Resident ID #1's unusually high Lovenox (an anticoagulant medication prescribed to prevent and treat harmful blood clots) dose despite multiple opportunities to identify and prevent the medication error. These failures resulted in Resident ID #1 receiving more than twice the appropriate dose of Lovenox on 13 occasions. …
D · No harm, potential for more than minimal, isolatedJuly 31, 2026
Based on clinical record review and staff interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice relative to following physician's orders for 1 of 2 residents reviewed who had an order for daily weights, Resident ID #130. Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician orders unless they believe the orders are in error or would harm the client.Review of the facility's undated policy titled Protocol for Addressing Weight Changes states, in part, .If applicable, the charge nurse may also notify the physician .Record review revealed the resident was admitted to the… …
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