Mansion Nursing and Rehab Center
For profit - Corporation
62 Beds
Independent
Data: November 2025
Trust Grade
70/100
#25 of 72 in RI
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Last Inspection: July 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Mansion Nursing and Rehab Center has a Trust Grade of B, indicating it is a good choice among nursing homes. Ranking #25 of 72 facilities in Rhode Island places it in the top half, while its #15 rank out of 41 in Providence County means only a few local options are better. The facility is improving, with issues decreasing from 10 in 2024 to 5 in 2025. Staffing is a concern, with a 3/5 rating and a turnover rate of 53%, which is higher than the state average. Although there have been no fines, which is a positive sign, the facility has faced issues such as improper food safety practices, including a dirty ice machine, and a lack of effective infection control measures, highlighting some areas that need attention.
- Trust Score
- B
- In Rhode Island
- #25/72
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 53% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Rhode Island facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 23 minutes of Registered Nurse (RN) attention daily — below average for Rhode Island. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 26 deficiencies on record. Higher than average. Multiple issues found across inspections.
70/100
Top 34%
No red flags
10 → 5 violations
★★★★☆
4.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 10 issues
2025: 5 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
Staff Turnover: 53%
Near Rhode Island avg (46%)
Higher turnover may affect care consistency
The Ugly 26 deficiencies on record
Jul 2025
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interviews, it has been determined that the facility failed to provide the necessary ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interviews, it has been determined that the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, for a resident who is diagnosed with a mental disorder and has a history of trauma, for 1 of 1 resident reviewed, Resident ID #28. Findings are as follows: Record review revealed that the resident was originally admitted to the facility in May of 2023 with diagnoses including, but not limited to, schizoaffective disorder, anxiety disorder, and post-traumatic stress disorder (PTSD). Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition. Review of a Mood Interview dated 7/3/2025 revealed a score of 12 out of 27, indicating the resident has moderate depression.Record review of a psychiatric consultation document dated 7/10/2025 revealed the resident reported that s/he was experiencing .excess anxiety and having trouble settling in and asks for medications. Further review revealed the following recommendations: -Switch Sertraline (a medication prescribed to treat depression and anxiety) 100 milligrams (mg) at bedtime to daytime.-Trial Prazosin (a medication prescribed off label to alleviate nightmares and sleep disturbances associated with PTSD) 1 mg at bedtime for nightmares and anxiety.Record review revealed the psychiatric consultation documentation was sent to the facility via fax on 7/17/2025, after the document was requested by the surveyor on 7/16/2025. Record review failed to reveal evidence that the physician was made aware of the medication recommendations. Further record review failed to reveal evidence that the medications were put into place as recommended.During a surveyor interview on 7/15/2025 at 9:27 AM with Resident ID #28, s/he indicated that s/he requested a change in medications for anxiety about a week ago, however, has not heard anything since. During a subsequent interview on 7/16/2025 at 1:42 PM with the resident, s/he indicated that s/he has been experiencing an increase in his/her anxiety level and is not sleeping well as a result. S/he further indicated that s/he has told the staff about it but hasn't received any additional medications to help alleviate the symptoms. During a surveyor interview on 7/18/2025 at 11:07 AM with Registered Nurse, Staff A, she indicated that the unit nurse is responsible for contacting the physician regarding psychiatric recommendations. She further indicated that she was told about the psychiatric recommendations the day before, however she did not review them or contact the physician.During a surveyor interview on 7/18/2025 at 11:15 AM with the Director of Nursing Services, she indicated that the psychiatric provider usually emails her with any recommendations, however a new provider completed Resident ID #28's consult and did not send an email. Additionally, she acknowledged that the psychiatric medication recommendations had not yet been reviewed by the physician and had not been put into place, eight days after the consultation took place and the recommendations were made.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for a...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for a medication with blood pressure parameters, Resident ID #3.Findings are as follows:Record review revealed the resident was admitted to the facility in February of 2025 with diagnoses including, but not limited to, hypertensive heart disease without heart failure and orthostatic hypotension (a decrease in blood pressure of 20 mm Hg or more systolic or 10 mm Hg or more diastolic within three minutes of standing from the supine position). Review of a physician's order dated 3/28/2025 revealed to administer midodrine (a medication prescribed to treat low blood pressure) 10 milligrams three times daily. Additionally, the special instructions indicate to hold the medication for a systolic blood pressure (the top number of the blood pressure reading) of more than 130.Review of the June and July 2025 Medication Administration Records (MARs) revealed that the resident received the medication when it was indicated to be held, per the physician's order on the following dates and times:- 6/9 6:00-7:00 AM with a documented blood pressure (BP) of: 133/88- 6/12 6:00-7:00 AM with a documented BP of: 133/95- 6/17 6:00-7:00 AM with a documented BP of: 139/87- 6/21 4:00-5:00 PM with a documented BP of: 132/92-7/14 6:00-7:00 AM with a documented BP of: 142/100During a surveyor interview on 7/18/2025 at 10:27 AM with Registered Nurse, Staff A, she acknowledged that the midodrine was signed off as administered on the above dates and times when it should have been held. During a surveyor interview on 7/18/2025 at 10:32 AM with the Director of Nursing Services, she was not able to provide evidence that the midodrine was held per the ordered parameters.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to ensure that the irregularities identified by the Clinical Consultant Pharmacist during the monthly pharma...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that the irregularities identified by the Clinical Consultant Pharmacist during the monthly pharmacist Medication Regimen Review (MRR) were acted upon for 4 of 4 residents reviewed, Resident ID #s 5, 7, 14, and 25. Findings are as follows:Review of a facility policy titled, Consultant Pharmacist Reports dated November 2021 states in part, .Recommendations are acted upon and documented by the facility staff and/or the prescriber. Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing .The Director of Nursing or designated licensed nurse address and document recommendations that do not require a physician intervention.1. Record review revealed that Resident ID #5 was admitted to the facility in November of 2023 with diagnoses including, but not limited to, dementia, major depressive disorder, anxiety, and post-traumatic stress disorder (PTSD). Record review of the pharmacist's progress note, dated 6/25/2025, states the following, JUNE PHARMACIST MEDICATION REGIMEN REVIEW See report for any noted irregularities/recommendations.Record review failed to reveal evidence of the June 2025 pharmacy recommendations.During a surveyor interview on 7/18/2025 at 9:41 AM with the Director of Nursing Services (DNS) she was unable to provide the pharmacy recommendation for June 2025.2. Record review revealed that Resident ID #7 was admitted to the facility in April of 2023 with diagnoses including, but not limited to, delusional disorder, personal history of mental and behavioral disorders and anxiety.Record review revealed the following physician's order for alprazolam (a medication prescribed to treat anxiety):-alprazolam 1 milligram (MG) three times a day, dated 8/18/2021Record review of the pharmacist's MRR, dated 3/19/2025, revealed the following recommendations: Consider a trial discontinuation of psychotropic medication alprazolam 1 mg three times a day due to a recent fall that resulted in a right distal femur fracture.Record review failed to reveal evidence that the pharmacy recommendation dated 3/19/2025 was reviewed by the provider.During a surveyor interview on 7/17/2025 at approximately 1:10 PM with the DNS, she could not provide evidence that the pharmacy recommendation was reviewed by the provider. 3. Record review revealed that Resident ID #14 was admitted to the facility in April of 2023 with diagnoses including, but not limited to, dementia with psychotic disturbance and delusional disorders.Record review revealed the following physician's order for Seroquel (a medication prescribed to treat schizophrenia, bipolar disorder, and major depressive disorder): -Seroquel 12.5 mg at bedtime, dated 4/5/2023Record review of the pharmacist's MRR, dated 4/29/2025, revealed the following recommendations: Consider a trial discontinuation of a short acting dose of Seroquel 12.5 mg at bedtime per resident's recent fall and the increased risk for falls while on psychotropic medications.Record review failed to reveal evidence that the pharmacy recommendation dated 4/29/2025 was reviewed by the provider.During a surveyor interview on 7/17/2025 at approximately 1:10 PM with the DNS, she could not provide evidence that the pharmacy recommendation was reviewed by the provider.4. Record review revealed that Resident ID #25 was readmitted to the facility in November of 2024 with diagnoses including, but not limited to, dementia, bipolar disorder, anxiety, and PTSD. Record review of the pharmacist's progress note, dated 6/25/2025, states the following, JUNE PHARMACIST MEDICATION REGIMEN REVIEW See report for any noted irregularities/recommendations.During a surveyor interview on 7/18/2025 at 9:41 AM with the DNS, she was unable to provide the pharmacy recommendation for June 2025.During a surveyor interview on 7/18/2025 at approximately 2:30 PM with the DNS, she was unable to provide evidence that the pharmacy consultation reports with noted irregularities for Resident ID #s 5, 7, 14, and 25 were reviewed by the provider and acted upon, as required.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on record review and staff interview, it has been determined that the facility failed to measure success and track performance of Quality Assurance and Performance Improvement (QAPI) actions to ...
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Based on record review and staff interview, it has been determined that the facility failed to measure success and track performance of Quality Assurance and Performance Improvement (QAPI) actions to ensure that problem areas are identified, and good faith efforts for improvements are achieved and sustained demonstrated by measurable objectives with statistical data documented.Findings are as follows:Record review of a facility policy titled, .Quality Assurance Performance Improvement QAPI PLAN 2025 . revealed in part, .Establish, maintain, support, and document evidence of an ongoing QAPI program that includes effective mechanisms for monitoring and evaluating resident care and for appropriate response to findings .Record review of the facility's 2024 and 2025 QAPI failed to reveal evidence of any actions, measurements, or tracking to ensure efforts for improvements of identified problem areas within the facility. During a surveyor interview on 7/18/2025 at approximately 11:00 AM with the Administrator, she was unable to provide evidence that the facility developed actions, measurements, or tracking systems to measure and track performance of identified problem areas within the facility.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0569
(Tag F0569)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to notify each resident, or resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to notify each resident, or resident representative, that receives Medicaid benefits upon death of a resident with a personal fund deposited with the facility, within 30 days of the resident's funds, and provide a final accounting of those funds to the individual or probate jurisdiction administering the resident's estate, in accordance with State law for 2 of 2 residents reviewed who expired with funds remaining at the facility, Resident ID #s 57 and 58. Findings are as follows:1a) Record review revealed Resident ID #57 was admitted to the facility in August of 2020 and expired on [DATE].Record review revealed that the facility was holding funds for Resident ID #57, but they were unable to provide evidence of the amount of funds that were continuing to be held. 1b) Record review revealed Resident ID #58 was originally admitted to the facility in October of 2022 and expired on [DATE].Record review revealed that the facility was holding funds for Resident ID #58, but they were unable to provide evidence of the amount of funds that were continuing to be held.During a surveyor interview on [DATE] at approximately 9:15 AM with the Administrator, she indicated that the facility was still holding funds for Resident ID #s 57 and 58. Additionally, she was unable to provide evidence that the facility conveyed the residents' funds within 30 days of the residents' deaths, or the final accounting of those funds, to the individual or probate jurisdiction administering the residents' estates.
Jul 2024
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure tha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice relative to following a physician's order for 1 of 1 residents reviewed for significant weight gain, Resident ID #38.
Findings are as follows:
According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
Record review revealed the resident was admitted to the facility in November of 2023 with a diagnosis including, but not limited to, type II diabetes mellitus.
Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition.
Review of a progress note authored by the Registered Dietician, Staff A, dated 6/9/2024 revealed s/he continues with significant weight gain and recommends bloodwork to check his/her thyroid panel.
Record review of a physician's order dated 6/19/2024 for bloodwork to include the following: T-3 total, T-3 Uptake (blood tests that help diagnose thyroid conditions, specifically hyperthyroidism) and TSH (blood test to find out if your thyroid gland is working properly).
Record review failed to reveal evidence of the above lab work results or documentation that it was completed.
During a surveyor interview on 7/3/2024 at 9:59 AM with Registered Nurse, Staff B, she acknowledged that the physician's order was not followed, and the lab work was not completed per the physician's order on 6/19/2024.
During a surveyor interview on 7/3/2024 at 1:30 PM with the Director of Nursing Services, she revealed that she would expect the lab work to be completed per the physician order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 ...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 residents reviewed for respiratory care, Resident ID #47.
Findings are as follows:
Record review of a facility policy titled, ProCare Oxygen Administration states in part, .A physician's order is necessary for the administration of oxygen .Verified the physician's order and review the patient chart .verify flow of oxygen .
Record review revealed Resident ID #47 was readmitted to the facility in June of 2024 with a diagnosis including, but not limited to, Chronic Obstructive Pulmonary Disease (a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe).
Review of a physician's order dated 6/21/2024 revealed an order for the resident to receive oxygen at 2 liters via a nasal cannula (a tubing that delivers oxygen into your nose) every shift.
During surveyor observations on the following dates and times, the resident was observed receiving oxygen at the following flow rate:
-7/1/2024 at 11:50 AM, the resident was receiving 3 liters of oxygen
-7/2/2024 at 8:32 AM, the resident was receiving 2.5 liters and at 1:40 PM the resident was receiving 3 liters of oxygen
-7/3/2024 at 8:28 AM, 11:48 AM, and at 1: 13 PM, the resident was receiving 3 liters of oxygen
During a surveyor observation on 7/3/2024 at 1:26 PM in the presence of the Director of Nursing Services (DNS) and a Registered Nurse, Staff B, they revealed the resident was receiving 3 liters of oxygen instead of the 2 liters as ordered.
During a surveyor interview immediately following this observation the DNS and Staff B acknowledged the resident was receiving 3 liters of oxygen instead of 2 liters as ordered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store all ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store all drugs and biological's in accordance with currently accepted professional principles for 1 of 1 medication storage room observed, 1 of 1 medication refrigerator, and 2 of 3 medication carts observed ([NAME] One and Two).
Findings are as follows:
Review of the facility policy titled LTC Facility's Pharmacy Services and Procedures Manual with a revision date of [DATE] states in part, Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record date opened on the primary medication container when the medication has a shorter expiration date once opened .If a multi-dose vial of an injectable medication has been opened or accessed, the vial should be dated and discarded within 28 days unless the manufacturer specifies a different date for the opened vial .
1. Surveyor observation of the medication refrigerator on the first floor on [DATE] at 11:28 AM in the presence of License Practical Nurse (LPN), Staff C, revealed a bottle of tuberculin purified protein derivative solution (a solution used in a skin test to help diagnose tuberculosis) opened and not dated.
During a surveyor interview immediately following this observation with Staff C, she acknowledged the above-mentioned solution was opened and not dated.
2. Surveyor observation of the [NAME] One medication cart narcotic drawer on [DATE] at 11:35 AM, in the presence of a LPN, Staff D revealed a packet of 31 tablets of Lorazepam 0.5 milligrams (mg- a medication used to treat anxiety) with a discontinue date of [DATE].
During a surveyor interview immediately following this observation with Staff D, she acknowledged the medication should have been removed from the drawer.
3. Surveyor observation of the [NAME] Two medication cart on [DATE] at 11:44 AM in the presence of Staff D revealed a Trelegy Ellipta 100 microgram (mcg)/62.5 MCG/25 MCG inhaler and a Incruse Ellipta 62.5 MCG inhaler (medications used to treat respiratory disease) opened and not dated. Manufacturer instructions indicate to discard 6 weeks after opening or when the counter reads 0 or whichever comes first.
During a surveyor interview immediately following this observation with Staff D, she acknowledged the inhalers were opened and not dated.
4. Surveyor observation of the medication storage room on [DATE] at 12:28 PM in the presence of the Director of Nursing Services (DNS), revealed the following:
- Two bottles of Vitamin E 400 international unit with an expiration date of 9/2019
- One bottle of Mucus relief tablet 400 MG with an expiration date of 12/2020
- Two bottles of Fish oil capsules with an expiration date of 9/2019
During a surveyor interview immediately following this observation with the DNS, she acknowledged the above-mentioned medications were expired and should have been discarded.
During an additional interview on [DATE] at 2:05 PM with the DNS, she could not provide evidence the above-mentioned medications were stored appropriately as required.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to maintain a safe, functiona...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to maintain a safe, functional, and comfortable environment for residents, staff, and the public relative to resident rooms and furnishings in disrepair on 3 of 6 units observed.
Findings are as follows:
1) During a surveyor observation on 7/3/2024 at 8:38 AM of the 2nd floor common area revealed an entertainment center with scattered chip marks and pieces of wood that were lifting, resulting in an uneven surface.
During a surveyor interview immediately following the above observation with the Operations Manager, he acknowledged that the entertainment center was in disrepair.
2) During a surveyor observation on 7/3/2024 at 1:19 PM of room [ROOM NUMBER] on the [NAME] 1 Unit, revealed 3 holes in the drywall measuring approximately 7 x 6 inches, 7 x 5 inches, and 19 x 5 inches. Additionally, the paint on the wall over the resident's bed was observed to be chipped.
3) During a surveyor observation on 7/3/2024 at 1:23 PM of room [ROOM NUMBER] on the Annex 1 Unit, revealed that the call light system box that was affixed to the wall had exposed wiring coming from the channel. Additionally, the paint was chipped on the wall behind the resident's bed and recliner.
During a surveyor interview on 7/3/2024 at approximately 1:25 PM with the Director of Nursing Services, she acknowledged the above findings and indicated they needed to be repaired.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on surveyor observation and staff interview, it has been determined that the facility failed to prepare, store, and distribute food according to professional standards of food service safety, re...
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Based on surveyor observation and staff interview, it has been determined that the facility failed to prepare, store, and distribute food according to professional standards of food service safety, relative to 1 of 1 ice machine and 1 of 1 kitchenette observed.
Findings are as follows:
1. During a surveyor observation on 7/1/2024 at 8:40 AM of the ice machine, revealed an accumulation of a pink substance located on the bottommost edge of the ice dispenser shield. Additionally, the pink substance was easily removed by wiping it with a paper towel.
During a surveyor interview immediately following the above observation with Licensed Practical Nurse, Staff D, she acknowledged the presence of the above-mentioned pink substance within the ice machine.
2. Review of the Rhode Island Food Code, 2018 Edition, section 3-501.17 states in part, .(B) .refrigerated, ready-to-eat time/temperature control for safety food .shall be clearly marked, at the time the original container is opened in a food establishment .and: (1) the day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date .
Review of the High-calorie (Hi-Cal) oral supplement Product Information guide states in part, .Storage and Handling .Once opened, reclose, label with time and date, refrigerate, cover and use within 48 hours .
During a surveyor observation on 7/1/2024 at approximately 8:40 AM of the kitchenette, revealed 1 opened bottle of Hi-Cal dated 5/7/2024, approximately 3/4th's full.
During a surveyor interview immediately following the above observation with Staff D, she acknowledged that the Hi-cal supplement was dated 5/7/2024 and should have been discarded.
During a surveyor interview on 7/1/2024 at 9:00 AM with the Food Service Director, he acknowledged the accumulation of the pink substance within the ice machine and the Hi-Cal supplement dated 5/7/2024. He further revealed the Hi-Cal supplement should be discarded and the ice machine needs to be cleaned.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, s...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections related to the implementation of water system management control measures to mitigate the development of Legionella (a very serious type of lung infection caused by the bacteria called Legionella which can be found in water) and other opportunistic waterborne pathogens for 1 of 1 ice scoop and designated container. Additionally, the facility failed to maintain Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) for 2 of 3 residents reviewed, Resident ID #s 20 and 26.
Findings as follows:
1) Record review of the Centers for Disease Control and Prevention document titled, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated June 2021, states in part, .The key to preventing Legionnaires' disease is maintenance of the water systems in which Legionella may grow .Water stagnation: Encourages biofilm growth and reduces temperature and levels of disinfectant .
During a surveyor observation of the nourishment area on 7/1/2024 at 8:57 AM, the ice scoop was observed submerged in approximately 2 inches of stagnant water in the designated ice scoop container.
During a surveyor interview immediately following the above observation on 7/1/2024 at 8:59 AM with Licensed Practical Nurse, Staff D, she acknowledged the ice scoop was submerged in approximately 2 inches of stagnant water.
During a surveyor interview with the Food Service Director, on 7/1/2024 at 9:05 AM, he acknowledged the above-mentioned observations and stated, It should not be in standing water, he then removed the ice scoop container from the wall to empty the stagnant water from the container. Additionally, he indicated this was the only ice machine and scoop for the entire facility.
2) Review of the Center for Disease Control and Prevention document titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs) Last Reviewed: August 1, 2023, states in part, Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities .The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents .with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include:
-Dressing
-Bathing/showering
-Transferring
-Providing hygiene
-Changing linens
-Changing briefs or assisting with toileting
-Device care or use of a device (i.e central lines, urinary catheters, feeding tubes .
2a) Record review revealed Resident ID #20 was readmitted to the facility in May of 2024 with diagnoses including, but not limited to, dementia and a wound on the right great toe.
Surveyor observation of signage posted on the resident's door on 7/2/2024 at approximately 1:40 PM revealed in part, Enhanced Barrier Precautions; Attention: Caregivers, staff and visitors .Wear Gown and Gloves prior to these activities .During high-contact resident care activities .transferring, changing linen .
During a surveyor observation on 7/2/2024 at approximately 1:44 PM, a Nursing Assistant (NA) Staff E, was observed not wearing a gown as required while in the resident's room changing his/her linens.
During a surveyor interview immediately following the above observation with Staff E, she acknowledged that she was changing the resident's linens and failed to wear a gown.
2b) Record review revealed Resident ID #26 was admitted to the facility in May of 2014 with diagnosis including, but not limited to schizoaffective disorder ( a mental health condition that is marked by a mixed of symptoms).
Surveyor observation of signage posted on the resident's door on 7/2/2024 at approximately 1:50 PM revealed in part, Enhanced Barrier Precautions; Attention: Caregivers, staff and visitors .Wear Gown and Gloves prior to these activities .During high-contact resident care activities .transferring .providing hygiene .changing linen .
During a surveyor observation on 7/2/2024 at approximately 1:51 PM, Staff E, she was observed not wearing a gown as required while in the resident's room providing assistance with personal hygiene and toileting.
During a surveyor interview immediately following the above observation with Staff E, she acknowledged that she had entered the resident's room and had assisted the resident with personal hygiene and toileting and failed to wear a gown.
During a surveyor interview on 7/3/2024 at 2:40 PM with the Director of Nursing Services (DNS) in the presence of the Administrator, she acknowledged that Resident ID #s 20 and 26 are on EBP. She further indicated that she would expect the staff to wear gowns when assisting the residents with toileting, changing linens, and personal hygiene as indicated on the signage posted.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0567
(Tag F0567)
Minor procedural issue · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to obtain written authorization for residents whom the facility is holding personal funds relative to 2 of 6...
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Based on record review and staff interview, it has been determined that the facility failed to obtain written authorization for residents whom the facility is holding personal funds relative to 2 of 6 residents reviewed Resident ID #s 10 and 38.
Findings are as follows:
Record review of the facility's records related to personal needs funds revealed a document titled, List of Residents Managed by Administrator revealed the facility was holding funds for Resident ID #s 10 and 38.
1. Record review revealed that Resident ID #10 was admitted to the facility in September of 2011.
Record review of a Personal Needs account balance document revealed Resident ID #10 had a current balance of $4,379.42 on 6/10/2024.
Record review of an Exhibit 'A' Authorization Document form dated 9/9/2011 revealed that the resident did not authorize the facility to hold their funds.
2. Record review revealed that Resident ID #38 was admitted to the facility in November of 2023.
Record review of a Personal Needs account balance document revealed Resident ID #38 had a current balance of $125.00 on 5/14/2024.
Record review of an Exhibit 'A' Authorization Document form dated 11/7/2023 revealed that the resident did not authorize the facility to hold their funds.
During a surveyor interview on 7/5/2024 at 11:27 AM with the Administrator, she acknowledged that the facility did not have written authorization to hold the funds for Resident ID #s 10 and 38.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0568
(Tag F0568)
Minor procedural issue · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident was given a written accounting of his/her deposits, withdrawals, and balances a...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident was given a written accounting of his/her deposits, withdrawals, and balances at least quarterly for 2 of 6 residents reviewed, Resident ID #s 3 and 38.
Findings are as follows:
1. Record review revealed that Resident ID #3 was admitted to the facility in May of 2023.
Review of a facility provided document titled, Personal Needs Account revealed that Resident ID #3 has funds being held by the facility.
Record review failed to reveal evidence that any quarterly statements were completed and given to Resident ID #3.
2. Record review revealed that Resident ID #38 was admitted to the facility in November of 2023.
Review of a facility provided document titled, Personal Needs Account revealed that Resident ID #38 has funds being held by the facility.
Record review failed to reveal evidence that any quarterly statements were completed and given to Resident ID #38.
During a surveyor interview on 7/5/2024 at 11:27 AM with the Administrator, she acknowledged that Resident ID #s 3 and 38 had not been provided a written accounting of his/her deposits, withdrawals, and balances at least quarterly per the regulation.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0569
(Tag F0569)
Minor procedural issue · This affected multiple residents
Based on record review and staff interview it has been determined that the facility failed to notify each resident, or resident representative, that receives Medicaid benefits when the amount in the r...
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Based on record review and staff interview it has been determined that the facility failed to notify each resident, or resident representative, that receives Medicaid benefits when the amount in the resident's account reaches $200 less than the Social Security Income (SSI) resource limit for 3 of 6 residents reviewed for personal needs funds handled by the facility, Resident ID #s 10, 16 and 17.
Findings are as follows:
Title 210-Executive Office of Health and Human Services, Chapter 50-Medicaid Long-Term Services and Supports (LTSS) under section 2.4 (G) of the Uniform Accountability Procedures for Title XIX Resident Personal Needs Funds in Community Nursing Facilities, ICF/DD Facilities, and Assisted Living Residences requires that the facility shall: .(10) The nursing facility must notify the resident in writing when his/her balance reaches $200.00 less than the resource eligibility guideline, that Medicaid eligibility is jeopardized if the account exceeds the guideline[4,000] .
Review of facility documents titled, List of Resident Managed by Administrator and Personal Needs Account for the following residents states in part:
- Resident ID #10 has a current balance of $4,370.42.
- Resident ID #16 has a current balance of $4,549.22.
- Resident ID #17 has a current balance of $4,186.66.
During a surveyor interview on 7/5/2024 at 11:27 AM with the Administrator, she was unable to provide evidence that the above identified residents were notified in writing that their account balances reached $200 less than the SSI Medicaid eligibility resource limit (4,000).
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0583
(Tag F0583)
Minor procedural issue · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide residents with the right to personal privacy and confidentiality of his/he...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide residents with the right to personal privacy and confidentiality of his/her personal and medical records relative to the posting of past survey results.
Findings are as follows:
During a surveyor observation of the main hallway area on 7/3/2024 at 8:15 AM, revealed a Survey Results envelope. In the envelope there were copies of previous survey rosters which included identifying information of residents from the following survey dates:
Record review of the Survey Results envelope revealed the following:
- Resident/Staff Roster form dated 10/4/2019 with four residents identified, ID #s 11, 106, 107 and 108.
- Resident/Staff Roster form dated 4/15/2021 with nine residents identified, ID #s 16, 109, 110, 111, 112, 113,
114, 115 and 116.
- Resident/Staff Roster form dated 6/16/2022 with eleven residents identified, ID #s 14, 17, 22, 42, 115, 117,
118, 119, 120, 121 and 122.
- Resident/Staff Roster form dated 7/21/2023 with three residents identified, ID #s 44, 123, and 124.
During a surveyor interview on 7/3/2024 at 8:30 AM with the Director of Nursing Services, she acknowledged that the resident rosters on the above-mentioned dates were available with the Survey Results.
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on surveyor observation and staff interview, it has been determined that the facility failed to maintain a clean, comfortable, and homelike environment relative to 1 of 1 resident room observed,...
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Based on surveyor observation and staff interview, it has been determined that the facility failed to maintain a clean, comfortable, and homelike environment relative to 1 of 1 resident room observed, Resident ID #1.
Findings are as follows:
Record review of a community reported complaint submitted to the Rhode Island Department of Health on 8/28/2023 alleges environmental concerns relative to a resident's room with peeling paint on the window casing, dresser drawers falling apart, and the drawers are not able to close properly. Additionally, one wall has a large patch of white plaster, and another wall has a linear area with the plaster missing and an additional hole. Further, the report mentioned that the baseboard heater cover was falling apart.
During surveyor observations of the resident's room on 8/29/2023 at approximately 5:30 PM in the presence of the Director of Nursing Services revealed the following:
-The left wall had an area approximately 10 in length (L) X 2 in width (W) with visible exposed plaster and wallboard.
-Beneath the left wall area there was a hole in the wall that measured approximately 2 in circumference with exposed plaster and wallboard.
-The back wall of the room revealed a hanging calendar and under the calendar was a larger visible white patch of spackle measuring approximately 11 X 11.
-One of the bedroom window sills has chipped paint to the lower portion of the wood.
-The bottom of the dresser drawer has the top layer broken off exposing the underlying particle board.
-The back of the bedroom door has chipped paint along the edge, adjacent to the door frame, starting parallel to the door handle down to the floor and chipped paint along the bottom of the door adjacent to the floor almost measuring the full length of the door. Also, close to the middle of the door revealed a smaller area with chipped paint.
- A portion of the baseboard heater cover had chipped paint.
During a surveyor interview on 8/29/2023 at approximately 5:45 PM with the Director of Operations, he revealed that imminent environmental projects are priority and that they were slowly going through the building of each resident's room, but that had stopped due to the economic hardships in the industry.
Jul 2023
8 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality regarding foll...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality regarding following a physician's order for 1 of 13 residents reviewed, Resident ID #8.
Findings are as follows:
Review of the record revealed the resident was admitted to the facility on hospice services in January of 2023 with diagnoses including, but not limited to, malignant neoplasm of the ascending colon (cancer of the colon), Alzheimer's disease, and dementia.
Review of the resident's care plan, updated on 5/9/2023, revealed s/he requires assistance with activities of daily living tasks with interventions including but not limited to offering 120 ml (milliliters) of DHS (dietary health supplement) if meal intake is less than 50%.
Review of the physician order report revealed a 1/30/2023 order to provide 120 ml DHS with meals if meal intake is less than 50%.
During a surveyor observation on 7/18/2023 at 12:34 PM of the resident's lunch meal revealed s/he consumed a few bites of a sandwich then walked away from the meal tray which contained a sandwich and cole slaw. Further observation failed to reveal evidence that a shake was offered to the resident as s/he was observed by the surveyor to consume less than 50% of his/her lunch as evidenced by only eating a few bites of the sandwich and no cole slaw.
Review of the record failed to reveal evidence of a breakfast or lunch meal intake percentage or supplement documentation for 7/18/2023.
During a surveyor observation on 7/20/2023 at 8:40 AM of the breakfast meal revealed only a small amount of the scrambled eggs were consumed by the resident. Further observation failed to reveal evidence that a shake was offered to the resident as s/he was observed by the surveyor to consume less than 50% of his/her breakfast. Certified Nursing Assistant, Staff A was observed retrieving the breakfast tray at 9:03 AM that contained eggs and toast and did not offer the resident a supplement at that time.
During a surveyor observation on 7/20/2023 at 12:37 PM, of the lunch meal revealed that the resident did not consume any of his/her meal. Further observation failed to reveal evidence that a shake was offered to the resident as s/he was observed by the surveyor to consume less than 50% of his/her lunch. Staff A was observed retrieving the lunch tray that the resident had not eaten at 12:44 PM and did not offer the resident a supplement at that time.
Although surveyor observations revealed the resident consumed less than 50% of his/her meal for breakfast and lunch on 7/20/2023, a review of the intake documentation revealed 51-75% intake for both meals.
During continuous observation by the surveyor on 7/21/2023 from 8:18 AM to 10:07 AM, of the breakfast meal, revealed s/he did not consume any of his/her meal. Additionally, the resident was not provided a supplement.
During a surveyor interview on 7/21/2023 at 10:47 AM with Staff A, she acknowledged that she failed to provide a dietary health supplement to the resident, when the resident consumed less than 50% of his/her meal. Additionally, she acknowledged the documentation for the breakfast and lunch meals on 7/20/2023 was inaccurate.
During an interview with the Director of Nursing Services on 7/21/2023 at 12:18 PM, she indicated that she would expect the meal intakes to be documented accurately and she would expect the physician's order for supplements be followed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0710
(Tag F0710)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to ensure that the medical care of each resident is supervised by a physician for 1 of 2 residents reviewed ...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that the medical care of each resident is supervised by a physician for 1 of 2 residents reviewed receiving anticoagulant therapy (medication that prevents or reduces the blood from clotting), Resident ID #45.
Findings are as follows:
Record review revealed the resident was admitted to the facility in October of 2022 with diagnoses including, but not limited to stroke, combined systolic and diastolic congestive heart failure (CHF)-heart pumps inadequately), hypertension (high blood pressure), and atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart).
Record review of the physician's orders revealed an order with a start date of 3/22/2023 for Eliquis 5 milligrams (mg) twice daily.
Record review of the nursing progress notes revealed the resident was noted to have blood in his/her stool on 4/11/2023 and the physician was notified and orders were received to obtain a complete blood count (CBC-blood test used to diagnose, and monitor many different conditions). Further review of the resident's laboratory results obtained on 4/11/2023, revealed the resident's hemoglobin was 9.0 (normal hemoglobin results range from 12.1 to 17.2). Additionally, on 4/14/2023 the resident's hemoglobin was rechecked and the results were 7.3 and s/he was subsequently transferred to an acute care hospital for further evaluation.
Record review of the hospital Continuity of Care (COC) document dated 4/19/2023 revealed the resident was admitted to the hospital and diagnosed with acute blood loss, anemia, and diverticulosis. Additionally, the resident's order for Eliquis was put on hold during his/her hospital stay.
Record review of a progress note dated 4/21/2023 authored by the Medical Director, Resident ID #45's physician, states in part, readmission .was hospitalized with severe anemia (hemoglobin 6.5). The patient reported having bleeding per rectum. Anticoagulation was initially held. [S/he] was transfused 2 units of packed red blood cells .and underwent an EGD [an endoscopic procedure to visualize the swallowing tube, stomach, and upper part of the small intestine] and colonoscopy .[s/he] was found to have diverticulosis (nonbleeding). No source of GI [gastrointestinal] bleed was found. [S/he] is now being readmitted .ASSESSMENT/PLAN .#2. Congestive heart failure/atrial fibrillation/hypertension .Eliquis 5 mg twice a day (currently on hold, consider restarting in 10-14 days. If no further bleeding, and CBC stable) .
Record review failed to reveal evidence that the physician addressed the resident's need to resume Eliquis as evidenced by the failure to order additional labs after the CBC results were received on 4/27/2023. This lab revealed a hemoglobin of 8.2. Despite the lab being drawn on 4/27/2023 neither the physician or the facility followed up with additional labs or interventions. This failure potentially resulted in the resident not receiving Eliquis from 4/27/2023 to present until the surveyor brought it to the facility's attention.
During a surveyor interview on 7/21/2023 at 1:56 PM with the resident's physician, he revealed that we could have done a better job with monitoring this resident and he was unable to explain what happened with the Eliquis order or labs.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with profess...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 3 residents reviewed for nutrition, Resident ID #8 and 1 of 2 residents reviewed for opioid administration, Resident ID #s 8 and 26.
Findings are as follows:
1. Review of the record for Resident ID #8 revealed that s/he was admitted to the facility on hospice services in January of 2023 with diagnoses including, but not limited to, malignant neoplasm of the ascending colon (cancer of the colon), Alzheimer's disease, and dementia.
Review of his/her care plan, updated on 5/9/2023, revealed s/he requires assistance with activities of daily living tasks with interventions including but not limited to offering 120 ml (milliliters) of DHS (dietary health supplement) if meal intake is less than 50%.
Review of the physician order report revealed a 1/30/2023 order to provide 120 cc (cubic centimeters) DHS with meals if meal intake is less than 50%.
During a surveyor observation on 7/20/2023 at 8:40 AM of the breakfast meal revealed only a small amount of the scrambled eggs were consumed by the resident. Further observation failed to reveal evidence that a shake was offered to the resident as s/he was observed by the surveyor to consume less than 50% of his/her breakfast.
During a surveyor observation on 7/20/2023 at 12:37 PM, of the lunch meal revealed that the resident did not consume any of his/her meal. Further observation failed to reveal evidence that a shake was offered to the resident as s/he was observed by the surveyor to consume less than 50% of his/her lunch.
Although surveyor observations revealed the resident consumed less than 50% of his/her meal for breakfast and lunch on 7/20/2023, a review of the intake documentation revealed 51-75% intake for both meals.
During continuous observation by the surveyor on 7/21/2023 from 8:18 AM to 10:07 AM, of the breakfast meal, revealed s/he did not consume any of his/her meal.
Review of the record revealed Certified Nursing Assistant, Staff A documented that the resident's meal intake for both the breakfast and lunch meals on 7/20/2023 was 51-75%.
During a surveyor interview on 7/21/2023 at 10:47 AM with Staff A, she acknowledged the resident's meal intake for the above-mentioned meals was less than 50% and that the meal intake she documented was not accurate.
During an interview with the Director of Nursing Services on 7/21/2023 at 12:18 PM, she indicated that her expectation would be that the nursing documentation would accurately reflect the resident's record.
2. Record review revealed Resident ID #26 was admitted to the facility in June of 2023 with a diagnosis including but not limited to, chronic pain syndrome.
Record review revealed a physician order dated 6/21/2023 for Oxycodone (a narcotic medication that is counted and recorded when administered) 10 milligrams (mg) every 4 hours as needed.
Review of the July 2023 controlled substance log revealed the following dates and times the Oxycodone was documented as being removed from the medication cart:
- 7/8/2023 at 10:00 PM
- 7/9/2023 at 8:30 AM
- 7/10/2023 at 1:00 AM, 6:00 AM, 4:00 PM and 9:30 PM
- 7/13/2023 at 5:45 PM and 10:45 PM
- 7/14/2023 at 2:45 PM
- 7/15/2023 at 11:30 PM
- 7/18/2023 at 6:00 PM and 10:00 PM
Review of the July 2023 Medication Administration Record failed to reveal evidence that the above dates and times were documented as being administered.
During a surveyor interview on 7/21/2023 at 3:36 PM, with the Director of Nursing Services, she acknowledged the inaccuracy of the July MAR and the controlled substance log. She indicated that nurses need to document in the MAR and in the narcotics log, when administering the medication.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0942
(Tag F0942)
Could have caused harm · This affected multiple residents
Based on record review and staff interview it has been determined that the facility failed to provide training to their staff, that at a minimum includes Resident's rights and facility responsibilitie...
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Based on record review and staff interview it has been determined that the facility failed to provide training to their staff, that at a minimum includes Resident's rights and facility responsibilities, for 7 out of 15 staff reviewed.
Findings are as follows:
Record review of the facility tracking system for Resident's Rights in-service training, failed to reveal evidence that the following staff were provided training or education:
- Registered Nurse, Staff C
- Licensed Practical Nurse, Staff D
- Certified Nursing Assistant, Staff E
- Cook, Staff F
- Dietary Aide, Staff G
- Laundry, Staff H
- Maintenance, Staff I
During a surveyor interview on 7/20/2023 at approximately 12:21 PM and again on 7/21/2023 at approximately 2:47 PM with the Administrator and the Director of Nursing Services, they were unable to provide evidence that the training was completed for the above-mentioned staff.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0943
(Tag F0943)
Could have caused harm · This affected multiple residents
Based on record review and staff interview it has been determined that the facility failed to provide training to their staff, that at a minimum includes abuse, neglect, exploitation, and misappropria...
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Based on record review and staff interview it has been determined that the facility failed to provide training to their staff, that at a minimum includes abuse, neglect, exploitation, and misappropriation of resident property and dementia management, for 7 out of 15 staff reviewed.
Findings are as follows:
Record review of the facility tracking system for abuse, neglect, exploitation, misappropriation of resident property, and dementia management in-service training, failed to reveal evidence that the following staff were provided training or education:
- Registered Nurse, Staff C
- Licensed Practical Nurse, Staff D
- Certified Nursing Assistant, Staff E
- Cook, Staff F
- Dietary Aide, Staff G
- Laundry, Staff H
- Maintenance, Staff I
During a surveyor interview on 7/20/2023 at approximately 12:21 PM and again on 7/21/2023 at approximately 2:47 PM, with the Administrator and the Director of Nursing Services, they were unable to provide evidence that the training was completed for the above-mentioned staff.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on surveyor observations and staff interview, it has been determined that the facility failed to properly store, distribute, and serve food, in accordance with professional standards for food se...
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Based on surveyor observations and staff interview, it has been determined that the facility failed to properly store, distribute, and serve food, in accordance with professional standards for food service safety, relative to the main kitchen and 1 of 1 kitchenette.
Findings are as follows:
During a surveyor observation of the main kitchen on 7/18/2023 at 7:50 AM, in the presence of the Food Service Director (FSD), revealed the following:
1. Sysco Classic Garlic 36 ounce (oz.) container open and not dated. Review of the manufacturers description of the item revealed in part, .After opening, store in refrigerator for two to three months .
During a surveyor interview with the FSD, at the time of the above observation, he could not explain why the item was not dated when opened. Additionally, he revealed that once the product is opened, it is their policy to keep the containers for 5 days after opening before it is discarded.
2. During a surveyor observation on 7/18/2023 at approximately 11:15 AM of the FSD obtaining the temperature the lunch meal before it was served to the residents revealed the following:
-The FSD cleaned the thermometer probe with an alcohol wipe and then placed the thermometer directly on the food preparation table with the tip resting directly on the unsanitized surface. The FSD took the thermometer from the table and proceeded to attempt to take the temperature of the meat without cleaning the thermometer again. At this time, the surveyor intervened before the thermometer was used. Additionally, the FSD was observed to remove his dirty gloves, collect the used alcohol pad packages, lift the trash can cover to discard those items with his bare hands and continued to attempt to take the temperature of the remaining food items without performing hand hygiene. At this time, the surveyor again intervened.
During a surveyor interview at the time of the observation with the FSD, he could not explain why he placed the thermometer on the unsanitized surface and then failed to disinfect the thermometer prior to attempting to take the temperature of the food item. In addition, he could not explain why he did not perform hand hygiene after touching the trash can lid and before he attempted to take temperatures of the remaining food items.
3. Review of The Rhode Island Food Code 2018 Edition 4.601.11 reads in part, .(A) equipment food contact surfaces .shall be clean to sight .
During a surveyor observation of the kitchenette on 7/19/2023 at approximately 2:00 PM revealed the inside of the ice machine had an accumulation of pink matter on the plastic surface of the inner wall where the ice is dispensed. Additionally, there was pink discoloration noted on multiple surface areas of the plastic. At this time, the surveyor performed hand hygiene, applied gloves and ran her gloved finger across the plastic surfaces where the pink residue was observed. The pink matter was had enough of an accumulation to be spread on a piece of paper towel.
During a surveyor interview with the FSD immediately following the above observation, he acknowledged the accumulation of pink matter. Additionally, he revealed that the ice machine is usually cleaned on a weekly basis but acknowledged the ice machine was not cleaned last week.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based on record review and staff interview, it has been determined that the facility failed to document a facility-wide assessment to determine what resources are necessary to care for its residents c...
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Based on record review and staff interview, it has been determined that the facility failed to document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies which must be reviewed and updated as necessary, and at least annually. Additionally, the facility failed to review and update the assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment.
Findings are as follows:
Record review revealed a document titled; Facility Assessment dated April 2023 capturing the Resident Population Profile-April 18, 2022- April 17, 2023, which failed to reveal the following components, according to Appendix PP:
- The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population
- The staff competencies that are necessary to provide the level and types of care needed for the resident population
- The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population
- Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services
Further review of the document titled Facility Assessment, failed to reveal evidence of the facility's resources, which include but are not limited to:
- All buildings and/or other physical structures and vehicles
- Equipment (medical and non- medical)
- Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies
- All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care
- Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and
- Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.
During a surveyor interview on 7/21/2023 at 2:47 PM with the Administrator, she acknowledged that the facility assessment was not completed when it was initially provided to the survey team on 7/18/2023. She acknowledged that she updated the facility assessment after the survey team brought their concerns to her attention. Additionally, she was unable to provide evidence that the template tool that the facility utilizes for their facility assessment was complete in order to reflect the current needs of the facility.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0944
(Tag F0944)
Minor procedural issue · This affected most or all residents
Based on record review and staff interview it has been determined that the facility failed to provide mandatory training to all their staff, that outlines and informs staff of the elements and goals o...
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Based on record review and staff interview it has been determined that the facility failed to provide mandatory training to all their staff, that outlines and informs staff of the elements and goals of the facility's QAPI (Quality Assurance and Performance Improvement) program, for 15 out of 15 staff reviewed.
Findings are as follows:
Record review of the facility tracking system for their QAPI in-service training failed to reveal evidence that the following staff were provided training or education:
- Certified Nursing Assistant, Staff B
- Registered Nurse, Staff C
- Licensed Practical Nurse, Staff D
- Certified Nursing Assistant, Staff E
- Cook, Staff F
- Dietary Aide, Staff G
- Laundry, Staff H
- Maintenance, Staff I
- Certified Nursing Assistant, Staff J
- Registered Nurse, Staff K
- Certified Nursing Assistant, Staff L
- Registered Nurse, Staff M
- Registered Nurse, Staff N
- Infection Preventionist
- Food Service Director
During a surveyor interview on 7/20/2023 at approximately 12:21 PM and again on 7/21/2023 at approximately 2:47 PM, with the Administrator and the Director of Nursing Services, they were unable to provide evidence that the training was completed for the above-mentioned staff.
Jun 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure the services provided by the facility meet professional standards of quality relative to following...
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Based on record review and staff interview, it has been determined that the facility failed to ensure the services provided by the facility meet professional standards of quality relative to following physician's orders for 1 of 3 residents reviewed, Resident ID #2.
Findings are as follows:
Record review revealed Resident ID #2 was admitted to the facility in December 2018 with diagnoses including, but not limited to, unspecified convulsions (rapid involuntary muscle contractions/seizures), Bipolar- disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Post traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and cocaine abuse.
Record review of a physician's order dated 1/11/2023 revealed an order for Abilify (anti-psychotic medication used to treat bipolar disorder) 2 milligram (mg) 1 tablet once a day.
Further review of physician orders revealed an order dated 10/27/2022 for Depakote Sprinkles (medication used to treat seizures) 125 mg, 2 capsules once in morning, and Depakote Sprinkles 125 mg, 9 capsules at bedtime.
Review of the May and June 2023 Medication Administration Records revealed the resident refused the above-mentioned medications as ordered on the following dates:
Abilify:
-5/20/2023
-5/26/2023
-5/29/2023
-5/31/2023
Depakote Sprinkles:
-5/20/2023
-5/23/2023
-5/26/2023
-5/29/2023
-5/31/2023
Review of a facility policy titled, Medication Administration Safety Program (MASP)-Physician Notification, states in part .When a regularly scheduled dose of medication is not administered due to a resident refusal, the physician should be notified .The charge nurse is responsible to notify physician in a timely manner .omission of critical medication is reported to the physician immediately .
During a surveyor interview on 6/6/2023 at 1:15 PM with charge nurse, Licensed Practical Nurse, Staff A, she indicated when a resident refuses medication, the standard of practice at the facility is as follows, the resident should be reproached after the initial refusal and if they continue to refuse the medication, the charge nurse should notify the physician and document in the resident's medical record that the physician was notified of the medication refusal.
During a surveyor interview on 6/6/2023 at 1:50 PM with the Director of Nursing Services, she acknowledged the facility policy for medication administration which includes notifying the physician of a resident's refusal. She further indicated that she would expect a charge nurse to immediately contact the physician upon a resident's refusal of a critical medication such as Depakote. Additionally, she was unable to provide evidence that the physician was notified of the above-mentioned medication omissions.
Dec 2022
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that staff utilize Personal Protective Equipment according to professional ...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that staff utilize Personal Protective Equipment according to professional standards to prevent the potential development and transmission of COVID-19 for 1 staff member, Nursing Assistant (NA), Staff A, relative to two residents who tested positive for COVID-19, Resident ID #s 1 and 2.
Findings are as follows:
Review of a CDC document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic last updated September 29,2022 states in part:
.Personal Protective Equipment .HCP [Healthcare Personnel] who enter the room of a patient with suspected or confirmed SARS-CoV-2 [COVID 19] infection should adhere to Standard Precautions and use a NIOSH [National Institute for Safety and Health] approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or face shield that covers the front and sides of the face) .
Review of the facility's infection control policies and procedures states in part:
.policy of this facility to prevent the spread of COVD-19 .personnel are to wear gloves, gown, facemasks, and goggles whenever exposure to COVID 19 is anticipated .remove and discard gloves when leaving the patient room, and immediately perform hand hygiene .
1. Record review revealed Resident ID #1 is on Covid 19 isolation precautions until 12/24/2022
Surveyor observation of the second floor on 12/16/2022 at 12:15 PM, revealed NA, Staff A was observed to be in Resident ID #1's room, delivering a meal tray, without a gown or a face shield on.
2. Record review revealed Resident #2 is on Covid 19 isolation precautions until 12/24/2022.
Additional surveyor observation on 12/16/2022 at approximately 12:20 PM revealed NA, Staff A exiting Resident ID #2's room with gloves on. Staff A was then observed taking off the gloves in the common area of the unit. Additionally, Staff A failed to perform hand hygiene after discarding the contaminated gloves.
During a surveyor interview on 12/16/2022 at approximately 12:20 PM with NA, Staff A, he acknowledged both
Resident ID# 1 and 2 are on precautions due to testing positive for COVID-19. Additionally, he acknowledged he should have worn a gown and a face shield while in Resident ID #1's room and that he should have taken his gloves off and performed hand hygiene before exiting the room of a COVID-19 positive resident's room.
During a surveyor interview with the Director of Nurses on 12/15/2022 at approximately 12:50 PM she revealed her expectations are that a gown and a face shield are to be worn when entering a COVID-19 positive resident's room. Additionally, she indicated that she would expect that gloves are removed prior to exiting a COVID-19 positive resident's room and hand hygiene is to be performed.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Rhode Island facilities.
Concerns
- • 26 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 70/100. Visit in person and ask pointed questions.
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About This Facility
What is Mansion Nursing And Rehab Center's CMS Rating?
CMS assigns Mansion Nursing and Rehab Center an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Rhode Island, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Mansion Nursing And Rehab Center Staffed?
CMS rates Mansion Nursing and Rehab Center's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 53%, compared to the Rhode Island average of 46%.
What Have Inspectors Found at Mansion Nursing And Rehab Center?
State health inspectors documented 26 deficiencies at Mansion Nursing and Rehab Center during 2022 to 2025. These included: 20 with potential for harm and 6 minor or isolated issues.
Who Owns and Operates Mansion Nursing And Rehab Center?
Mansion Nursing and Rehab Center is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 62 certified beds and approximately 53 residents (about 85% occupancy), it is a smaller facility located in Central Falls, Rhode Island.
How Does Mansion Nursing And Rehab Center Compare to Other Rhode Island Nursing Homes?
Compared to the 100 nursing homes in Rhode Island, Mansion Nursing and Rehab Center's overall rating (4 stars) is above the state average of 3.1, staff turnover (53%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Mansion Nursing And Rehab Center?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Mansion Nursing And Rehab Center Safe?
Based on CMS inspection data, Mansion Nursing and Rehab Center has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Rhode Island. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Mansion Nursing And Rehab Center Stick Around?
Mansion Nursing and Rehab Center has a staff turnover rate of 53%, which is 7 percentage points above the Rhode Island average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Mansion Nursing And Rehab Center Ever Fined?
Mansion Nursing and Rehab Center has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Mansion Nursing And Rehab Center on Any Federal Watch List?
Mansion Nursing and Rehab Center is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.