Based on clinical record review, resident interview, and staff interview, the facility failed to ensure that residents were free from significant medication errors for 1 of 1 resident reviewed, Resident ID #1. Specifically, the facility administered 50 units of short-acting insulin to the resident instead of the prescribed 50 units of long-acting insulin. This medication error resulted in the resident receiving a medication with a substantially different onset, peak, and duration of action than ordered. The facility's failure to administer the medication as prescribed placed the resident at immediate risk for serious hypoglycemia, loss of consciousness, hospitalization, or death. …
F760 citations in Rhode Island
Significant medication errors · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Rhode Island cites F760 more often than its own record predicts
3.73 times the share F760 takes of citations nationally.
Of every deficiency written in Rhode Island in 2025, this is the portion that was F760.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Rhode Island surveyors wrote
F760 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 interviews, the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed who did not receive intravenous antibiotic therapy as ordered, Resident ID #1. Findings are as follows:Record review revealed the resident was admitted to the facility on [DATE] with a diagnosis including, but not limited to, a urinary tract infection (UTI).Review of the hospital Discharge summary dated [DATE] revealed the resident was to receive Meropenem (an antibiotic) 1 gram (g) in 50 milliliters (mL) of normal saline, intravenously every eight hours for six days. …
Based on clinical record review and staff interview, the facility failed to ensure that residents are free of any significant medication errors, for 1 of 1 resident reviewed for buspirone (a medication prescribed to reduce anxiety) administration, Resident ID #1.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 7/15/2026 alleged that Resident ID #1 was administered triple the dose of his/her ordered buspirone as s/he should have been receiving 7.5 milligrams (mg).Review of an undated facility policy titled Medication Administration Safety Program (MASP) - Safety Guidelines states in part, .It is the policy of this facility that resident shall receive medications in a safe and timely manner and in accordance with… …
The short window
Recent years
| Year | Share of Rhode Island citations | vs expected |
|---|---|---|
| 2023 | 3.61% | 3.25× |
| 2024 | 5.77% | 4.94× |
| 2025 | 4.85% | 3.73× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Rhode Island surveyors cite →
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