Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mansion Nursing And Rehab Center during CMS and state inspections, most recent first.
A Registered Nurse on an overnight shift failed to complete the medication pass and required treatments, monitoring, and documentation for most residents under her care. Record review showed that medication and treatment orders were not carried out for 40 of 48 residents reviewed during that shift, and the only drugs documented as given were Oxycodone, Ritalin, and Lorazepam, with documentation noted as inaccurate. When the missing documentation was discovered by the oncoming shift, the DON and Administrator suspected possible diversion by the agency nurse and were unable to produce evidence that residents received their ordered medications and treatments in accordance with professional standards of practice.
A resident with multiple medical conditions, including a recent fracture, sepsis, and opioid use disorder, was transferred to the hospital after a verbal altercation with staff. The facility did not provide the required written information about its bed-hold policy to the resident or their representative prior to the transfer, as confirmed by record review and staff interviews.
A resident with a history of opioid addiction and other medical conditions did not receive prescribed Methadone for two days due to the medication being unavailable. The DON reported delays in obtaining the medication from the treatment center, and the resident exhibited behavioral changes during this period. The facility could not demonstrate that the resident was kept free from significant medication errors.
The facility did not establish or document actions, measurements, or tracking systems to monitor and improve identified problem areas as required by its QAPI program. Review of records and staff interview confirmed the absence of evidence showing that performance improvement efforts were measured or tracked.
The facility did not ensure that pharmacy recommendations from monthly medication regimen reviews were reviewed or acted upon for four residents with complex psychiatric and medical conditions. Documentation and staff interviews confirmed that recommendations regarding medication changes or discontinuations, especially after incidents like falls, were not addressed as required by facility policy.
A resident with schizoaffective disorder, anxiety disorder, and PTSD did not receive recommended changes to psychiatric medications after a consultation, due to a lack of communication and follow-through among staff. The resident continued to experience increased anxiety and sleep disturbances, and the recommended medication adjustments were not implemented or reviewed by the physician.
A resident with a history of hypertensive heart disease and orthostatic hypotension was given midodrine despite physician orders to hold the medication when systolic BP exceeded 130 mm Hg. MAR review showed the medication was administered multiple times outside of these parameters, and staff interviews confirmed the failure to follow the order.
The facility did not notify or provide a final accounting of personal funds for two residents who died while receiving Medicaid benefits. Funds were still being held by the facility, and there was no evidence that the required notifications or conveyance of funds to the appropriate parties or probate jurisdiction occurred within the mandated timeframe.
Surveyors observed deficiencies in food safety standards, including a pink substance in the ice machine and an expired Hi-Cal supplement in the kitchenette. Both the LPN and Food Service Director acknowledged these issues.
The facility failed to maintain infection control by allowing an ice scoop to sit in stagnant water, risking Legionella growth. Additionally, two residents requiring Enhanced Barrier Precautions (EBP) did not receive proper care, as a Nursing Assistant was observed not wearing a gown during high-contact activities. The Director of Nursing acknowledged these lapses.
The facility failed to properly store and label medications, as observed by surveyors. An LPN acknowledged undated and improperly stored medications, including a tuberculin solution, Lorazepam tablets, and inhalers. Additionally, expired medications were found in the storage room, which the DNS confirmed should have been discarded.
Surveyors identified deficiencies in the facility's environment, including disrepair in the 2nd floor common area and resident rooms. An entertainment center had an uneven surface, and rooms had holes in drywall, chipped paint, and exposed wiring. The Operations Manager and DON acknowledged these issues.
A resident with type II diabetes mellitus experienced significant weight gain, prompting a physician's order for thyroid-related blood tests. However, the facility failed to complete the ordered lab work. A Registered Nurse acknowledged the oversight, and the DON confirmed the expectation for the lab work to be completed, highlighting a failure to meet professional standards of practice.
A resident with COPD was prescribed 2 liters of oxygen per minute, but was observed receiving higher flow rates, up to 3 liters, on multiple occasions. This discrepancy was confirmed by the DON and a nurse during a surveyor interview.
The facility failed to obtain written authorization to manage personal funds for two residents. One resident, admitted in 2011, had a balance of $4,379.42, and another, admitted in 2023, had a balance of $125.00, both without authorization. The Administrator acknowledged this oversight during an interview.
The facility did not provide quarterly financial statements to two residents who had funds held by the facility. Despite having personal needs accounts, these residents did not receive the required written accounting of their deposits, withdrawals, and balances. The Administrator confirmed the oversight during an interview.
The facility failed to notify residents receiving Medicaid benefits when their account balances approached the SSI resource limit, as required by regulations. Three residents had balances exceeding the threshold, and the Administrator could not provide evidence of written notifications.
The facility breached resident confidentiality by posting past survey results in a public area, which included identifying information of residents from previous surveys. The DON confirmed the availability of these rosters, indicating a failure to protect residents' personal and medical records.
Failure to Administer and Document Medications and Treatments During Overnight Shift
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received treatment and care in accordance with professional standards of practice by not following provider orders for medications and treatments during a specific overnight shift. A facility-reported incident dated 1/14/2026 indicated that during the 11:00 PM to 7:00 AM shift on 1/2/2026, a Registered Nurse (Staff A) did not fulfill assigned nursing responsibilities. Record review showed that medication orders were not administered and treatment orders were not completed for 40 of 48 residents reviewed during that shift, covering the period from 11:00 PM on 1/2/2026 into 7:00 AM on 1/3/2026. Surveyor interviews with the Director of Nursing Services (DNS) and the Administrator on 1/20/2026 revealed that when the oncoming shift identified missing documentation, their initial concern was possible medication diversion by the agency nurse. The only medications documented as administered during the shift were Oxycodone, Ritalin, and Lorazepam, and the DNS and Administrator stated that the nurse’s documentation was inaccurate. They reported that when contacted, the agency nurse refused to return to the facility to complete the documentation. The DNS and Administrator were unable to provide evidence that residents received their ordered medications and treatments in accordance with professional standards of practice during the 11:00 PM to 7:00 AM timeframe in question.
Failure to Provide Bed-Hold Policy Notification Upon Hospital Transfer
Penalty
Summary
The facility failed to provide written information regarding its bed-hold policy to a resident or the resident's representative prior to the resident's transfer to a hospital. According to the facility's own Bed Hold Policy, residents and/or their representatives must be informed of the policy whenever a resident is transferred for hospitalization or therapeutic leave. However, clinical record review and staff interviews confirmed that this requirement was not met for a resident who was transferred to the hospital following a verbal altercation with staff. The resident in question had been admitted with multiple diagnoses, including an intertrochanteric fracture of the left femur with surgical repair, sepsis secondary to cellulitis of the left lower extremity, and was on daily Methadone for opioid use disorder. Despite these complex medical needs, there was no documentation in the clinical record that the resident was offered a bed-hold upon transfer. Both the DON and the Administrator confirmed during interviews that the required notification was not provided.
Failure to Administer Prescribed Methadone Due to Medication Unavailability
Penalty
Summary
A deficiency occurred when a resident admitted with multiple diagnoses, including a left femur fracture with surgical repair and sepsis secondary to cellulitis, did not receive prescribed Methadone for opioid addiction. The resident had physician orders for Methadone 40 mg in the morning and 60 mg in the evening, but the Medication Administration Record (MAR) showed that both doses were missed on two consecutive days. Documentation indicated that the medication was unavailable as the reason for the missed doses. The Director of Nursing (DON) reported that the orders for Methadone were faxed to the substance abuse treatment center after it had closed, and despite multiple calls and messages, the medication did not arrive until the resident's third day at the facility. During this period, the resident exhibited behavioral changes, including verbal aggression, which led to a behavioral health evaluation. The facility was unable to provide evidence that the resident was kept free from significant medication errors, as the resident never received the prescribed Methadone during their stay.
Failure to Measure and Track QAPI Performance
Penalty
Summary
The facility failed to implement and document effective mechanisms for monitoring and evaluating resident care as part of its Quality Assurance and Performance Improvement (QAPI) program. Record review of the facility's QAPI plan for 2024 and 2025 showed no evidence of actions, measurements, or tracking systems to ensure that efforts for improvement in identified problem areas were being made or sustained. During an interview, the Administrator was unable to provide documentation demonstrating that the facility had developed or used any actions, measurements, or tracking systems to monitor performance in these areas. This deficiency was identified through both record review and staff interview.
Failure to Act on Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that irregularities identified by the Clinical Consultant Pharmacist during monthly Medication Regimen Reviews (MRR) were acted upon for four residents. According to facility policy, recommendations from the pharmacist are to be addressed and documented by staff or the prescriber, with the prescriber either accepting and acting upon the suggestion or providing an explanation for disagreement. For each of the four residents reviewed, there was no evidence that pharmacy recommendations were reviewed or acted upon by the provider or facility staff, as required by policy. Specifically, for residents with diagnoses such as dementia, major depressive disorder, anxiety, PTSD, delusional disorder, and bipolar disorder, pharmacy recommendations regarding medication adjustments or discontinuations following incidents such as falls were not documented as reviewed or addressed. Interviews with the Director of Nursing Services confirmed the absence of documentation or evidence that these recommendations were considered or acted upon for the residents in question.
Failure to Implement Psychiatric Medication Recommendations for Resident with Mental Health Diagnoses
Penalty
Summary
A resident with diagnoses including schizoaffective disorder, anxiety disorder, and PTSD was admitted to the facility and later reported increased anxiety and sleep disturbances. The resident underwent a psychiatric consultation, which resulted in recommendations to adjust current medications and initiate a new medication to address nightmares and anxiety. The psychiatric consultation document containing these recommendations was sent to the facility, but there was no evidence that the physician was made aware of the recommendations or that the medication changes were implemented. Interviews with the resident revealed ongoing symptoms and repeated requests for medication changes, which were not addressed. Staff interviews indicated a lack of communication and follow-through regarding the psychiatric recommendations, with the responsible nurse not reviewing or acting on the recommendations and the DON acknowledging that the recommendations had not been reviewed or implemented by the physician, even eight days after the consultation. This failure resulted in the resident not receiving necessary behavioral health care and services as required.
Failure to Hold Medication per Blood Pressure Parameters
Penalty
Summary
A resident with hypertensive heart disease and orthostatic hypotension was admitted to the facility and prescribed midodrine 10 mg three times daily, with specific instructions to hold the medication if the systolic blood pressure exceeded 130 mm Hg. Review of the Medication Administration Records for June and July 2025 showed that the resident received midodrine on multiple occasions when their systolic blood pressure was above the ordered threshold, contrary to the physician's instructions. During interviews, a registered nurse confirmed that the medication was administered despite the parameters, and the Director of Nursing Services was unable to provide evidence that the medication was held as ordered.
Failure to Notify and Convey Resident Funds After Death
Penalty
Summary
The facility failed to notify the appropriate individuals or probate jurisdiction of the personal funds held for two residents who received Medicaid benefits and expired while residing at the facility. Record review showed that the facility was holding funds for both residents at the time of their deaths, but was unable to provide evidence of the amount of funds being held. Additionally, there was no documentation that the facility conveyed the residents' funds or provided a final accounting of those funds within 30 days of the residents' deaths, as required by state law. During an interview, the Administrator confirmed that the funds were still being held and that no evidence of notification or final accounting could be provided.
Deficiencies in Food Safety Standards Observed
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as observed during a survey. An inspection of the ice machine revealed an accumulation of a pink substance on the bottommost edge of the ice dispenser shield, which was easily removable with a paper towel. This observation was confirmed by a Licensed Practical Nurse, who acknowledged the presence of the substance. Additionally, the Food Service Director also confirmed the accumulation of the pink substance within the ice machine. Further inspection of the kitchenette revealed an opened bottle of Hi-Cal oral supplement dated 5/7/2024, which was approximately three-quarters full. According to the product information guide, once opened, the supplement should be labeled with the time and date, refrigerated, covered, and used within 48 hours. The LPN acknowledged that the Hi-Cal supplement was past its use-by date and should have been discarded. The Food Service Director also confirmed that the Hi-Cal supplement should have been discarded.
Infection Control and EBP Failures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by surveyor observations and staff interviews. During an inspection of the nourishment area, an ice scoop was found submerged in approximately 2 inches of stagnant water in its designated container. This was acknowledged by both a Licensed Practical Nurse and the Food Service Director, who confirmed that the ice scoop should not be in standing water. This oversight in water management could potentially lead to the growth of Legionella and other waterborne pathogens, posing a risk to the residents and staff. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) for two residents. Resident ID #20, who was readmitted with dementia and a wound on the right great toe, had signage indicating the need for gown and glove use during high-contact activities. However, a Nursing Assistant was observed changing the resident's linens without wearing a gown. Similarly, Resident ID #26, with a diagnosis of schizoaffective disorder, required EBP during personal hygiene and toileting assistance. The same Nursing Assistant was observed not wearing a gown while providing these services. The Director of Nursing Services acknowledged the failure to follow EBP protocols for these residents.
Deficiencies in Medication Storage and Labeling
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with accepted professional principles, as observed during a survey. In the medication refrigerator, a bottle of tuberculin purified protein derivative solution was found opened and undated, which was acknowledged by the LPN present. Additionally, a medication cart contained a packet of Lorazepam tablets with a discontinue date that had passed, and the LPN confirmed that the medication should have been removed. Furthermore, two inhalers on another medication cart were opened and undated, contrary to manufacturer instructions, which was also acknowledged by the LPN. In the medication storage room, several expired medications were found, including bottles of Vitamin E, Mucus relief tablets, and Fish oil capsules. The Director of Nursing Services acknowledged that these medications were expired and should have been discarded. During a follow-up interview, the DNS could not provide evidence that the medications were stored appropriately as required.
Facility Environment Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment for residents, staff, and the public, as observed by surveyors on three of six units. On the 2nd floor common area, an entertainment center was found with scattered chip marks and pieces of wood lifting, creating an uneven surface. The Operations Manager acknowledged the disrepair. In a resident room on the [NAME] 1 Unit, three holes in the drywall and chipped paint over the resident's bed were observed. In another room on the Annex 1 Unit, exposed wiring from a call light system box and chipped paint behind the resident's bed and recliner were noted. The Director of Nursing Services acknowledged these findings and indicated the need for repairs.
Failure to Follow Physician's Order for Bloodwork
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice by not following a physician's order for a resident with significant weight gain. The resident, who was admitted with a diagnosis including type II diabetes mellitus, had a Minimum Data Set assessment indicating intact cognition. A Registered Dietician recommended bloodwork to check the resident's thyroid panel due to continued significant weight gain. A physician's order was issued for specific thyroid-related blood tests, including T-3 total, T-3 Uptake, and TSH, to diagnose potential thyroid conditions. However, a review of the records did not reveal any evidence that the ordered lab work was completed. During interviews, a Registered Nurse acknowledged that the physician's order was not followed, and the lab work was not conducted as ordered. The Director of Nursing Services also confirmed that she would have expected the lab work to be completed according to the physician's order, indicating a lapse in following professional standards of practice within the facility.
Failure to Adhere to Oxygen Administration Orders
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident with Chronic Obstructive Pulmonary Disease (COPD). The resident was readmitted to the facility with a physician's order to receive oxygen at 2 liters per minute via a nasal cannula every shift. However, surveyor observations revealed that the resident was receiving oxygen at higher flow rates than prescribed. On multiple occasions, the resident was observed receiving 3 liters of oxygen, and on one occasion, 2.5 liters. During an observation in the presence of the Director of Nursing Services and a Registered Nurse, it was confirmed that the resident was receiving 3 liters of oxygen instead of the ordered 2 liters. Both the Director of Nursing Services and the Registered Nurse acknowledged this discrepancy during a surveyor interview.
Failure to Obtain Written Authorization for Managing Residents' Funds
Penalty
Summary
The facility failed to obtain written authorization to manage personal funds for two residents. Resident ID #10, admitted in September 2011, had a personal needs account balance of $4,379.42 as of June 10, 2024, without having authorized the facility to hold these funds, as indicated by the absence of an authorization document dated September 9, 2011. Similarly, Resident ID #38, admitted in November 2023, had a personal needs account balance of $125.00 as of May 14, 2024, without providing written authorization for the facility to manage their funds, as shown by the lack of an authorization document dated November 7, 2023. During an interview on July 5, 2024, the Administrator acknowledged the absence of written authorization for holding the funds of these two residents. This oversight indicates a failure in the facility's process for managing residents' financial affairs, as required by regulations.
Failure to Provide Quarterly Financial Statements to Residents
Penalty
Summary
The facility failed to provide a written accounting of deposits, withdrawals, and balances at least quarterly for two residents. Resident ID #3, admitted in May 2023, had funds held by the facility, but there was no evidence of quarterly statements being completed and provided. Similarly, Resident ID #38, admitted in November 2023, also had funds held by the facility without any quarterly statements being issued. During an interview, the Administrator acknowledged that these residents had not received the required written accounting of their personal funds as per the regulation.
Failure to Notify Residents of Medicaid Eligibility Risk
Penalty
Summary
The facility failed to notify residents or their representatives who receive Medicaid benefits when their account balances reached $200 less than the Social Security Income (SSI) resource limit. This deficiency was identified for three residents whose personal needs funds were managed by the facility. Specifically, Resident ID #10 had a balance of $4,370.42, Resident ID #16 had a balance of $4,549.22, and Resident ID #17 had a balance of $4,186.66. According to Title 210-Executive Office of Health and Human Services, Chapter 50-Medicaid Long-Term Services and Supports (LTSS), the facility is required to notify residents in writing when their balance approaches the SSI Medicaid eligibility resource limit of $4,000. During an interview, the Administrator was unable to provide evidence that these notifications were made, resulting in a failure to comply with the regulatory requirement.
Breach of Resident Confidentiality in Survey Results Posting
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical records, as evidenced by the posting of past survey results in a public area. During a surveyor observation in the main hallway, a Survey Results envelope was found containing copies of previous survey rosters with identifying information of residents. These rosters included resident IDs from surveys conducted on various dates, specifically 10/4/2019, 4/15/2021, 6/16/2022, and 7/21/2023. The Director of Nursing Services confirmed that these resident rosters were accessible with the Survey Results, indicating a breach of privacy and confidentiality for the residents involved.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Central Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harris Health Care Center North | 0.8 mi | ★★★★★ | 24 | 0 |
| Jeanne Jugan Residence | 1.3 mi | ★★★★★ | 3 | 0 |
| Adviniacare Pawtucket Pleasant Rehab Center, Llc | 1.4 mi | ★★★★★ | 14 | 0 |
| Grandview Center | 1.7 mi | ★★★★★ | 6 | 0 |
| Adviniacare Summit Commons, Llc | 1.8 mi | ★★★★★ | 15 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.