Based on clinical record review and staff interview, it has been determined that the facility failed to implement and maintain an effective, comprehensive, data-driven, Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life, related to 2 of 2 certified medication technicians (CMT) evaluations reviewed, Staff N and O. Findings are as follows:Record review of the QAPI binder on 12/19/2025 at 12:00 PM with the Administrator and Regional Director of Nursing Services, revealed a performance improvement plan was implemented on 6/17/2024 to establish a tracking system for employee evaluations which included CMT evaluations. …
F865 citations in Rhode Island
QAPI program · Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Rhode Island cites F865 more often than its own record predicts
4.37 times the share F865 takes of citations nationally.
Of every deficiency written in Rhode Island in 2025, this is the portion that was F865.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Rhode Island surveyors wrote
F865 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.
The short window
Recent years
| Year | Share of Rhode Island citations | vs expected |
|---|---|---|
| 2023 | 0.57% | 3.31× |
| 2024 | 0.30% | 1.59× |
| 2025 | 1.04% | 4.37× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Rhode Island surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction