Based on surveyor observation, clinical record review, and staff interviews, the facility failed to ensure a system was in place to prepare and serve fluids in a form designed to meet residents prescribed dietary needs. Specifically, the facility failed to ensure nectar thick liquids (mildly thick fluid consistency required to promote safe swallowing) were prepared according to physician's orders for 1 of 1 resident reviewed who was prescribed nectar thick liquids, Resident ID #21. Additionally, the current styrofoam cup supply, located on 4 of 4 units, was found to consist of 16 fluid (fl.) ounce (oz.) cups instead of the 12 fl. oz cups that were posted in the facility for staff to use for guidance and instructions when preparing thickened liquids. …
F805 citations in Rhode Island
Food in a form residents can eat · Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Rhode Island cites F805 more often than its own record predicts
2.27 times the share F805 takes of citations nationally.
Of every deficiency written in Rhode Island in 2025, this is the portion that was F805.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Rhode Island surveyors wrote
F805 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 ensure that residents receive and consume food in the appropriate form for 1 of 4 residents observed, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 2/13/2023 alleges in part, .almost choked on a pizza .does not have teeth .dentures were lost by the facility. Record review of a progress note dated 2/9/2023 at 10:36 PM states in part, .slice of pizza was given to resident by activities staff member .Res [resident] .showing visible sign of distress .started abdominal thrusts known as Helmlich [Sic] .a piece of pizza came out of [his/her] mouth . …
Based on surveyor observation, staff interview, and clinical record review, the facility failed to ensure food and fluids were provided in a modified form designed to meet the individual clinical needs for 1 of 1 resident reviewed for therapeutic diets, Resident #7. Findings are as follows:According to the OnTray, LLC. Long Term Care Diet Manual, 2025 Edition, provided by the facility, .Popsicles, Ice Cream, Sherbert, Freeze Pops, Frozen Lemonade, slushies, milk shakes, or any product that melts at body temperature .cannot be thickened.Record review revealed that Resident ID #7 was admitted to the facility in April of 2024 with a diagnosis including, but not limited to, dysphagia (difficulty swallowing).Record review revealed a physician's order dated 3/10/2026 specifying a therapeutic… …
The short window
Recent years
| Year | Share of Rhode Island citations | vs expected |
|---|---|---|
| 2023 | 0.76% | 2.15× |
| 2024 | 1.63% | 4.50× |
| 2025 | 0.69% | 2.27× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Rhode Island surveyors cite →
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