Mansion Nursing and Rehab Center
104 Clay Street, Central Falls, RI 02863 · For profit - Corporation · 62 certified beds · (401) 722-0830 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for mishandling residents’ money or property (F0567, F0568, F0569)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $22,205 in federal fines (most recent 2026-06-01)
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.5% | 19.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.7% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.1% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.0% | 2.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 3.1% | 17.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 6.4% | 3.6% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 18.7% | 16.8% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 32.4% | 16.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 89.3% | 95.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.9% | 4.2% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 19.1% | 22.3% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 41.4% | 22.8% | 17.1% | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.08 therapist hours per resident per day in 2026Q1 — more than 4% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 62 beds and averages 50.1 residents a day — about 81% occupied, or roughly 12 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.06 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.18 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.93 hrs/resident/day on weekends vs 3.11 on weekdays — 6% thinner on weekends. RN hours go from 0.40 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.
- Immediate jeopardy · Jcited before2026-06-01 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and staff interview, the facility failed to ensure residents were free from significant medication errors for 1 of 1 resident reviewed. Resident ID #1 was inadvertently administered multiple medications by the nurse assigned to Resident ID #1's roommate, Resident ID #2. The medications included, an insulin injection, two antipsychotics, an antidiabetic, a benzodiazepine, an anticonvulsant, two antidepressants, a laxative, and eye drops. Additionally, Resident ID #1 was previously administered his/her prescribed morning medications from the Medication Aide prior to mistakenly receiving his/her roommate's medications. As a result of the errors, Resident ID #1 became unresponsive and hypoglycemic (a condition that occurs when your blood sugar level drops below a healthy range) and required hospitalization. Findings are as follows:Review of a facility reported incident submitted to the Rhode Island Department of Health on 5/26/2026, indicated that Resident ID #1 was inadvertently administered medications intended for another resident and s/he was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-01-21 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following provider orders for 40 of 48 residents reviewed, Resident ID #s 1 through 40.Findings are as follows:Record review of a facility-reported incident dated 1/14/2026 and submitted to the Rhode Island Department of Health revealed that during the 11:00 PM to 7:00 AM shift on 1/2/2026, Registered Nurse (Staff A) failed to fulfill assigned nursing responsibilities, including failure to complete the medication administration pass and failure to complete required treatments, monitoring, and documentation for the entire shift. Record review of the facility schedule revealed Staff A worked during the 11:00 PM to 7:00 AM shift on 1/2/2026.Record review failed to reveal medication orders were administered from 11:00 PM to 7:00 AM on 1/2/2026 into 1/3/2026 for 40 of 48 residents reviewed.Record review failed to reveal treatment orders were completed on the 11:00 PM to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-16 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to ensure that before a resident is transferred to a hospital or the resident goes on therapeutic leave that the facility provides written information to the resident or resident representative that specifies information about the bed hold policy, for Resident ID #1.Findings are as follows:Review of the facility's Bed Hold Policy, states in part, Whenever a resident is transferred from the facility for the purposes of hospitalization or therapeutic leave, the resident and/or representative is informed of the facility's policy concerning holding the bed. Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/11/2025, alleges in part, the resident was not given the right medication/dosages, was not offered a bed-hold when sent out to the hospital for a behavioral health evaluation. Record review revealed Resident ID #1 was admitted to the facility in November of 2025 with diagnoses including, but not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-16 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review and staff interview, the facility failed to ensure that residents are free of any significant medication errors for one of three residents reviewed, Resident ID #1.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/11/2025, alleges in part, that the resident did not receive his/her methadone (a medication prescribed to treat opioid addiction). Record review revealed Resident ID #1 was admitted to the facility in November of 2025 with diagnoses including, but not limited to, fracture of left femur with surgical repair, sepsis secondary to cellulitis (a bacterial skin infection that causes redness, swelling, and pain, typically affecting the lower legs) of the left lower extremity, and receives daily Methadone. Record review of the Medication Administration Record (MAR) for the month of November 2025, revealed a physician's order dated 11/25/2025 for Methadone Schedule II tablet, 40 milligrams (mg) once daily in the morning and 60 mg in once daily in the evening. Further review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-07-18 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
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,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-07-18 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-18 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-18 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-07-05 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-07-05 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
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,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-05 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
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.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · E2024-07-05 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-05 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-29 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-07-21 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-07-21 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-21 · tag F0710 — patternObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-21 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-21 · tag F0942 — patternEnsure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
What the surveyor found here — the official record, unedited, may be distressing
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.
- Potential for harm · E2023-07-21 · tag F0943 — patternGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
What the surveyor found here — the official record, unedited, may be distressing
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.
- Potential for harm · Dcited before2023-07-21 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2025-07-18 · tag F0569 — patternNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-07-05 · tag F0567 — failed to protect residents' money held by the home — patternHonor the resident's right to manage his or her financial affairs.
What the surveyor found here — an excerpt from the official record, may be distressing
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.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-07-05 · tag F0568 — patternProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2024-07-05 · tag F0569 — patternNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-07-05 · tag F0583 — failed to protect personal privacy — patternKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
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,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2023-07-21 · tag F0944 — widespreadConduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$22,205 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $22,205 — penalty dated 2026-06-01
- Medicare payment denial — starting 2026-06-20 for 9 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MANSION, INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/28/2007 |
| CHOPOORIAN, JOHN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER | 50% | since 05/22/1989 |
| CHOPOORIAN, TERESA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER | NO PERCENTAGE PROVIDED | since 05/22/1989 |
CMS files one row per role, so the 9 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in RI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Rhode Island Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 415097. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-18, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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