Mansion Nursing and Rehab Center

In the surveyor’s words

From the most serious findings on record at Mansion Nursing and Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Jun 1, 2026

  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. […]

• No harm, potential for more than minimal, widespreadF812Jul 27, 2026

  Based on surveyor observations, record review, and staff interview, the facility failed to ensure that food is stored in accordance with professional food safety standards relative to the main kitchen.Findings are as follows:1. Review of the Rhode Island Food Code 2022 edition states in part, .Section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.refrigerated, Ready-to-eat, Time/Time Temperature Control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed.(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed… […]

• No harm, potential for more than minimal, widespreadF867Jul 27, 2026

  Based on record review and staff interview, it was determined that the facility failed to provide evidence of an ongoing system to monitor, track, measure and evaluate the facility's Quality Assurance and Performance Improvement (QAPI) program to ensure improvements are realized and sustained.Findings are as follows:Record review of the facility's QAPI program documents failed to reveal evidence that the facility has monitored, tracked, measured, and evaluated any of their performance improvement projects.During a surveyor interview on 7/27/2026 at 11:44 AM with the Administrator, she was unable to provide evidence of monitoring, tracking, measuring, and evaluating any of their performance improvement projects.

• No harm, potential for more than minimal, widespreadF867Jul 18, 2025

  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 . […]

• No harm, potential for more than minimal, widespreadF812Jul 5, 2024

  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. […]