Based on record review, surveyor observations, staff and resident interviews, the facility failed to provide an environment that remained as free of accident hazards as possible and failed to implement adequate supervision and interventions to prevent avoidable harm. Specifically, the facility failed to ensure safe water temperatures in resident-accessible hand sinks throughout all four resident care floors, exposing residents to the potential for serious burn injuries. In addition, the facility failed to ensure that Resident ID #2 received timely and appropriate post-fall assessment, monitoring, and interventions in accordance with facility policy following a fall, placing the resident at risk for undetected injury and potential worsening of condition. Findings are as follows:1. …
F689 citations in Rhode Island
Accidents and supervision · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Rhode Island cites F689 less often than its own record predicts
0.91 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 F689.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Rhode Island surveyors wrote
F689 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 resident and staff interviews, the facility failed to ensure that adequate supervision and assistive devices were provided to prevent an avoidable accident for 1 of 1 resident reviewed for accidents, Resident #77. Specifically, the facility failed to implement the resident's care-planned intervention requiring a two-person assist for bed mobility and turning/repositioning. As a result, a Nursing Assistant (NA) provided care to the resident without another staff member, resulting in the resident rolling from the bed onto the floor and sustaining an avoidable right tibia/fibula fracture that required emergency department evaluation, treatment, and pain management. …
Based on record review and staff interview, the facility failed to ensure that the resident environment remains as free of accident hazards as possible, as staff failed to follow established safety protocols to prevent and extinguish a kitchen grease fire. Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health by the State Fire Marshal on 8/24/2026 revealed that the facility had a small stove fire over the weekend.Review of a facility provided undated procedure titled GREASE FIRE SAFETY & PREVENTION EDUCATION states in part, .Cooking grease and oil can become extremely hot and may ignite. …
The short window
Recent years
| Year | Share of Rhode Island citations | vs expected |
|---|---|---|
| 2023 | 5.89% | 1.19× |
| 2024 | 4.44% | 0.82× |
| 2025 | 5.03% | 0.91× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Rhode Island surveyors cite →
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