Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Mansfield Center For Nursing And Rehabilitation during CMS and state inspections, most recent first.
Controlled substances were not properly secured or reconciled after a resident with severe dementia and hospice status expired. An ADNS and an LPN removed the resident’s Lorazepam and other controlled meds from the cart, but the meds were placed in a plastic bag, stored in a locked file cabinet that was not a proper double-locked controlled substance cabinet, and not reconciled with the DNS for several days. A later audit found a Lorazepam discrepancy, with one reconciliation sheet and one bottle unaccounted for.
A resident with hypothyroidism, anxiety, and dermatitis had multiple ordered medications, including Levothyroxine, Xanax, and Dupixent, that were not administered as prescribed, with MAR entries showing missed doses and not‑available status despite prior delivery from the pharmacy. Nursing notes and APRN documentation did not show that the physician or APRN were notified of missed Levothyroxine and Xanax doses, and a later APRN note linked missed morning Xanax doses to intermittent seizure‑like activity. Interviews with the DNS and LPNs confirmed that doses were omitted, medications were sometimes incorrectly documented as not available, and providers were not notified of these omissions, in contrast to facility policy requiring timely administration and appropriate notification.
A resident with anxiety, dermatitis, and hypothyroidism did not consistently receive ordered medications, including Levothyroxine, Xanax, and Dupixent, as documented on the MAR. Levothyroxine doses were missed on consecutive days, with one omission unexplained and another marked as not available despite prior delivery from the pharmacy, and no provider notification was documented. A scheduled Dupixent dose was delayed due to unavailability, and a Xanax dose was missed and marked as not available even though the medication had been received, again without documented provider notification. An APRN later noted the resident experienced intermittent seizure-like activity when the morning Xanax dose was missed and stated she should have been notified of omissions. Interviews with the DNS and LPNs revealed issues with agency staff marking medications as not available, failure to verify and obtain medications from stock or pharmacy, and lack of provider notification, contrary to facility medication administration and documentation policy.
A resident with severe cognitive and physical impairments, requiring two-person assistance for mechanical lift transfers, was transferred by a single nurse aide who failed to secure all sling loops and did not follow safety protocols. The resident, who was restless and on anticoagulant therapy, tipped forward during the transfer and sustained a head injury. The incident was not immediately reported, and other staff confirmed they did not assist or witness the transfer.
A resident with severe dementia and mobility impairments was injured during a mechanical lift transfer when a nurse aide, working alone, failed to follow the care plan's behavioral interventions and did not request assistance despite the resident's agitation. The resident struck their head on the lift after a sling loop detached, and the incident was not reported to nursing staff until injuries were later discovered.
Multiple residents were transferred using mechanical lifts by only one staff member, despite care plans and facility policy requiring two staff for such transfers. In one case, a resident sustained a leg fracture due to improper use of the lift and lack of required safety measures. Staff interviews and documentation confirmed awareness of the two-person requirement, but it was not consistently followed.
Surveyors found that food items in the kitchen were not labeled with expiration or open dates, and staff with facial hair, including the Dietary Manager and a Dietary Aide, plated food without wearing required beard restraints. Facility policy requires proper labeling of food and the use of hair and beard restraints during food handling.
Staff did not consistently use required PPE when providing care to a resident on Enhanced Barrier Precautions for a chronic wound, and infection control surveillance reports were found to be incomplete, lacking key data and analysis. Despite clear care plans and facility policies, observations and staff interviews confirmed lapses in both PPE use and infection documentation.
The facility did not complete or review required antibiotic surveillance reports at medical staff meetings, and a resident received antibiotics for a UTI despite lab results indicating colonization or contamination and not meeting McGeer's criteria. Staff interviews confirmed that antibiotic stewardship protocols were not consistently followed, and antibiotics were administered without proper indication.
The facility did not maintain a complete and accurate system for recording the receipt and disposition of controlled medications. Audits were performed, but reconciliation between yellow and white Controlled Substance Disposition Records was incomplete and delayed, and audit sheets were missing. The ADNS did not audit records until receiving documentation from nursing units, resulting in inadequate reconciliation and failure to meet the facility's policy for controlled drug record keeping.
A resident with significant mobility deficits and multiple diagnoses required two-person assistance for mechanical lift transfers. During a transfer performed by a single aide, the resident's foot slipped, resulting in an incident that was not followed by a registered nurse assessment or proper documentation, despite facility policy requiring such action. The resident was later found to have a leg fracture after reporting pain and swelling.
A controlled medication prescribed for a resident with anxiety and depressive disorder was found missing after a shift change. The medication was last verified during a count by two nurses, but one nurse left the medication cart keys unsecured and the incoming nurse did not immediately take possession of them. This lapse in medication security and accountability resulted in the loss of nearly all tablets from the resident's supply.
A resident's controlled medication, Ativan, was discovered missing, and the facility failed to report the incident to state authorities within the required two-hour window. The delay occurred despite internal awareness of the missing medication and an ongoing investigation, with external agencies not notified until several days after the initial discovery.
A resident with a history of stroke and dysphagia developed worsening respiratory symptoms, including a productive cough and abnormal lung sounds, over several days. Nursing staff documented these changes but did not notify the provider until the resident experienced further decline, including altered mental status and hypoxemia, resulting in hospitalization for probable aspiration pneumonia. Facility policy required prompt provider notification for changes in condition, which was not followed in this case.
A resident with hemiplegia and intact cognition submitted a grievance requesting more frequent care checks, timely linen changes, and specific hygiene assistance. Although the facility discussed these concerns in a care plan meeting, the resident's care plan and care card were not updated to reflect the preferences, and there was no documentation of staff education on the new care needs.
A resident with left-sided weakness and a history of falls was provided with a new mattress and bed frame, but necessary fall prevention measures, such as bolsters, were not included with the new equipment. The omission led to the resident falling from bed and sustaining shoulder pain.
A resident with essential tremor did not receive medications as per physician orders due to transcription errors and supply issues. Propranolol was given in a non-extended-release form, and Bupropion was omitted because it was not available. The DNS confirmed these errors during an interview.
Controlled Substance Not Secured and Reconciled
Penalty
Summary
Controlled substances were not securely stored and accounted for after a resident with cerebral atherosclerosis, dementia, and a cardiac pacemaker expired. The resident had severely impaired cognition, was receiving hospice services, and had orders for Lorazepam for anxiety/restlessness. Facility records showed Lorazepam bottles were received and later returned, but one Lorazepam bottle became unaccounted for during the reconciliation and disposal process. After the resident’s death, an ADNS and an LPN removed the resident’s controlled substances from the medication cart and completed a dual sign-off. Video footage showed the ADNS placing the controlled substances into a plastic bag and storing them in a locked controlled substance box in the ADNS office, then later transferring them to a locked controlled substance box in the DNS office. The ADNS could not recall how many reconciliation sheets were removed, and the DNS later found a Lorazepam discrepancy when conducting a random controlled substance audit. The DNS had one yellow reconciliation sheet but no white sheet for the Lorazepam bottle, and the investigation identified that one white reconciliation sheet and one controlled substance were not reconciled. Observation of the DNS office and Staff Development office found free-standing file cabinets with locked drawers, but the cabinets were not permanently affixed and did not contain a secondary locked compartment for controlled substances. The facility’s Controlled Substance Handling policy required controlled drugs to be stored in a two-door double locked cabinet with separate keys, separate from other drugs. Interviews indicated the controlled substances should have been brought directly to the DNS for reconciliation, but instead were stored in a file cabinet in the Staff Development office and were not reconciled for seven days, during which the bottle remained unaccounted for.
Failure to Notify Provider of Missed Medications and Omissions
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician when ordered medications were not administered as prescribed for one resident reviewed for medication administration. The resident had intact cognition and diagnoses including anxiety, dermatitis, and hypothyroidism, with care plans directing thyroid replacement therapy as ordered and psychotropic medications as ordered, with monitoring and reporting of issues. Physician orders included daily Levothyroxine for hypothyroidism, daily Xanax for anxiety, and biweekly Dupixent injections for dermatitis. Review of the MAR showed Levothyroxine was not documented as administered on two consecutive days, with one entry indicating the drug was not available and on order, despite pharmacy records showing a 30‑tablet supply had been delivered earlier. Nursing notes did not show that the physician was notified of these missed Levothyroxine doses. The MAR also showed a scheduled Dupixent dose was not given on the due date because it was not available and was administered two days later, with documentation that the physician was notified only to renew the Dupixent order date, not regarding the delay in administration. Additionally, a daily Xanax dose was missed on one day due to being marked as not available, and although the medication was ordered and received that same day, there was no documentation that the physician was notified of the missed dose. APRN progress notes around these timeframes did not reflect any notification of the medication omissions, and a later APRN note documented that the resident experienced intermittent seizure‑like activity when the morning Xanax dose was missed. Interviews with the DNS and LPNs confirmed that Levothyroxine and Xanax doses had not been administered as ordered, that staff documented medications as not available, and that the providers were not notified of these omissions, contrary to facility expectations and policy for medication administration and documentation.
Failure to Administer and Document Ordered Medications and Notify Provider of Omissions
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered for one resident with anxiety, dermatitis, and hypothyroidism. The resident had intact cognition and was care planned to receive thyroid replacement therapy daily and antianxiety medication as ordered, with monitoring and documentation of effects. Physician orders for March directed daily Levothyroxine for hypothyroidism, daily Xanax for anxiety, and Dupixent every 14 days for dermatitis. Review of the March MAR showed Levothyroxine was not documented as administered on two consecutive days, with one day lacking any explanation and the next day marked as not available and on order, despite pharmacy records showing a 30-tablet supply had been delivered earlier. Nursing notes did not show that the physician was notified of these missed Levothyroxine doses. The MAR also showed Dupixent was not administered on a scheduled date due to unavailability and was given two days later, after the order was renewed with a new start date. Xanax was not documented as administered on one day due to being marked as not available, even though pharmacy records indicated it had been ordered and received that same day, and there was no documentation that the provider was notified of this omission. An APRN progress note later documented that the resident continued to experience intermittent seizure-like activity when the morning dose of Xanax was missed, and the APRN stated she should have been notified of medication omissions. Interviews with the DNS and LPNs confirmed that Levothyroxine should have been available, that there were issues with agency staff documenting medications as not available, that required checks of emergency stock and pharmacy contact were not carried out as per facility expectations, and that providers were not notified when medications were not administered, contrary to facility policy on medication administration and documentation.
Failure to Ensure Two-Person Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe dementia, hemiplegia, hemiparesis, muscle weakness, and a history of subarachnoid hemorrhage, who was dependent on staff for all activities of daily living and required two-person assistance for mechanical lift transfers, was transferred by only one nurse aide using a mechanical lift. The resident was noted to be fidgety, anxious, restless, and flailing arms at the time of the transfer. Despite these behaviors, the nurse aide proceeded with the transfer alone, contrary to the resident's care plan and facility policy, which required two staff members for such transfers. During the transfer, one of the loops on the lift sling became detached from the hook, causing the resident to tip forward in the sling and strike their head on the mast of the lift. The nurse aide admitted to being in a rush and failing to ensure all loops were securely attached before lifting the resident. After the incident, the nurse aide lowered the resident back into the wheelchair, secured the loop, and completed the transfer to bed without notifying a nurse or reporting the incident at that time. The resident was later found by an LPN to have a raised, discolored area above the right eye and minor bleeding near the right ear, which had not been present earlier. Due to the resident's cognitive impairment, they were unable to communicate what had happened. The incident was initially treated as an injury of unknown origin until the nurse aide later reported the accident. Interviews with other staff confirmed that no one assisted the nurse aide during the transfer, and the required safety checks and reporting procedures were not followed.
Failure to Follow Care Plan During Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan during a mechanical lift transfer, resulting in the resident sustaining an injury. The resident had severe dementia with agitation, hemiplegia, hemiparesis, muscle weakness, and required substantial assistance with mobility and transfers. The care plan specified interventions for behavioral symptoms, including offering diversion, redirection, calm communication, step-by-step explanations, stopping care if the resident became combative or resistive, and notifying the provider if behaviors increased or persisted. On the evening of the incident, a nurse aide attempted to transfer the resident from a wheelchair to bed using a mechanical lift while the resident was visibly anxious, restless, and flailing their arms. Despite these behaviors, the aide proceeded with the transfer alone, without reporting the behaviors to nursing staff or requesting assistance, as required by the care plan and facility policy. During the transfer, a loop on the lift became detached, causing the resident to tip forward and strike their head on the lift's mast. The aide then completed the transfer without notifying nursing staff of the incident or the resident's behaviors. Later, nursing staff discovered injuries to the resident's head and ear, which were not present earlier in the day. The resident was sent to the emergency department for evaluation, where a forehead hematoma was diagnosed. The incident was initially treated as an injury of unknown origin until the aide reported the details of the transfer. Interviews confirmed that the aide did not follow the prescribed interventions for managing the resident's behaviors and did not adhere to the requirement for two staff during mechanical lift transfers.
Failure to Ensure Required Staff Assistance During Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that required staff assistance was utilized during mechanical lift transfers for multiple residents, as observed and documented in the clinical records and through staff interviews. For one resident with metabolic encephalopathy, dementia, and renal failure, staff were observed transferring the resident from the bathroom to a wheelchair using a mechanical lift with only one staff member present, despite care plans, physician orders, and facility policy requiring two staff for such transfers. The nurse aide involved acknowledged awareness of the two-person requirement but proceeded alone, and this was confirmed by interviews with other staff and review of facility policy. Another resident with Alzheimer's disease, aphasia, muscle weakness, and chronic kidney disease suffered a left tibia and fibula fracture following a mechanical lift transfer performed by a single nurse aide. The aide did not use the required leg support straps and failed to ensure the resident's feet remained on the lift platform, resulting in the resident's leg slipping and subsequent injury. Documentation and interviews confirmed that the resident required two staff for transfers and that the lift's safety features were not properly used. The incident was not initially acknowledged in the facility's reportable event documentation, and the aide admitted to performing the transfer alone due to lack of available assistance. A third resident with dementia, diabetes, anemia, and hemiplegia was also transferred using a mechanical lift by a single staff member, contrary to care plan instructions and facility policy. The staff member stated she was trained by other staff that only one person was needed, despite documentation and interviews with the DNS, staff development nurse, and physical therapist confirming the two-person requirement. These failures to follow established protocols and care plans for mechanical lift transfers resulted in unsafe conditions and, in one case, resident injury.
Failure to Label Food and Use Beard Restraints in Kitchen
Penalty
Summary
Surveyors observed multiple instances where food items stored in the facility's refrigerators and freezers were not labeled with expiration or open dates. Specifically, an open package of waffles, a partially consumed Starbucks mocha drink, shredded cabbage, Parmesan cheese wrapped in saran wrap, a box of pizza slices, a package of beef patties, an opened package of hot dogs, and oatmeal raisin cookie dough were all found without proper labeling. The Dietary Manager confirmed during interviews that these items should have been labeled with both the date they were opened and their expiration dates, in accordance with facility policy. Additionally, staff members, including the Dietary Manager and a Dietary Aide, were observed plating food without wearing required beard restraints, despite having facial hair. The facility's policies mandate that hair restraints, including beard guards, must be worn at all times in the kitchen and that facial hair should be fully covered. The Dietary Manager acknowledged during interviews that beard restraints should have been worn during food preparation.
Failure to Ensure PPE Use and Complete Infection Surveillance Documentation
Penalty
Summary
The facility failed to ensure that staff consistently used appropriate personal protective equipment (PPE) when providing care to a resident on Enhanced Barrier Precautions (EBP) and did not maintain complete infection control surveillance data. During the review of the infection control program for April 2023 to January 2024, it was found that monthly surveillance infection reports and analysis of infection trends were incomplete. The facility relied on monthly Antibiotic Reports for surveillance, but these reports lacked critical information such as whether infections were healthcare-associated or community-acquired, if McGeer's criteria were met, and details on new prophylactic treatments. Interviews with facility staff confirmed that the infection control surveillance reports were incomplete during this period, and it was the responsibility of the Infection Preventionist at the time to complete and analyze these reports. A resident with a history of neurocognitive disorder, Lewy bodies dementia, trigeminal neuralgia, and a sacral pressure ulcer was identified as requiring EBP due to a chronic wound. The care plan specified the use of gown and gloves during high-contact care activities. However, observations revealed that staff did not consistently follow these precautions. On multiple occasions, staff members provided wound care and incontinence care to the resident without donning the required PPE, such as gowns and masks, despite clear indicators (blue dots on name plaques) that the resident was on EBP. Staff interviews confirmed awareness of the EBP requirements, but they could not explain the failure to use PPE during care. Facility policy required maintaining separate infection records for each resident with an infection, analyzing clusters, and monitoring the infection control program quarterly or as indicated at quality improvement meetings. Despite these policies, the facility did not ensure complete documentation or consistent PPE use, as evidenced by direct observation and staff interviews. The lack of adherence to EBP protocols and incomplete infection surveillance documentation constituted the identified deficiencies.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure that its antibiotic stewardship program was properly implemented and monitored, as required by policy. During a review of the program, it was found that the antibiotic surveillance tracking report, which should include data on antibiotic use, patterns, and resistance trends, was not completed or reviewed at quarterly medical staff meetings for the period of April 2023 to January 2024. Monthly antibiotic reports were also found to be incomplete, missing key information such as infection source, whether McGeer's criteria were met, and details on new prophylactic use. Quarterly reports lacked any information regarding the antibiotic stewardship program, and staff interviews confirmed that the responsibility for completing these reports was not fulfilled during the period in question. For one resident reviewed for unnecessary medications, the facility did not follow its antibiotic stewardship protocols. The resident, who had diagnoses including metabolic encephalopathy, chronic kidney disease stage 4, and altered mental status, was administered antibiotics for a urinary tract infection (UTI) despite laboratory results suggesting colonization or contamination rather than infection. The resident's care plan included both treatment and prophylactic antibiotics, and medication administration records confirmed that these were given as ordered. However, progress notes and lab results indicated that urine cultures showed multiple organisms with no predominant species, and the resident did not exhibit classic symptoms of UTI. Staff interviews revealed that antibiotics were continued even when McGeer's criteria were not met, and the process for reviewing these criteria was not consistently followed. Further interviews with clinical staff and the medical director highlighted inconsistencies in the application of antibiotic stewardship practices. The infection preventionist noted an increase in antibiotic prescribing for UTIs that did not meet established criteria, and the APRN acknowledged not always using McGeer's criteria, citing altered mental status as a justification. The medical director stated that antibiotics should not be continued without culture sensitivity and suggested alternative treatments. The facility's own policy requires oversight and monitoring of antibiotic use to minimize resistance, but these procedures were not adhered to, resulting in the administration of antibiotics without proper indication.
Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to establish a complete and accurate system for recording the receipt and disposition of all controlled medications. During a review of the bi-monthly narcotic drug audit, it was found that while audits were being conducted to check for locked medication carts, proof of use sheets, correct narcotic counts, signed shift change count sheets, correct labeling, and removal of expired medications, there was a lack of comprehensive reconciliation between the yellow and white Controlled Substance Disposition Records (CSDR). The oldest yellow CSDR sheet had not been reconciled with the corresponding white CSDR, nor had the medications been documented as destroyed, and audit sheets were missing from the record book. An interview with the ADNS revealed that she was responsible for the controlled drug audits, which were performed twice a month. However, she stated that she did not audit the yellow CSDR sheets until she received the white CSDR sheets from the nursing units, resulting in incomplete and delayed reconciliation. The facility's own policy required special record keeping for all controlled drugs, but the current practice did not ensure adequate medication reconciliation, leaving the system vulnerable to medication diversion.
Failure to Complete RN Assessment After Mechanical Lift Incident
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, aphasia, muscle weakness, and chronic kidney disease, who required maximal assistance for mobility and transfers, was not assessed by a registered nurse following an incident during a mechanical lift transfer. The resident's care plan and aide care card specified the need for two staff members to assist with transfers using the Sara or Hoyer lift. However, on the day of the incident, a nurse aide performed the transfer alone due to lack of available assistance. During the transfer, the resident's left foot slipped off the lift platform, and the resident reported leg weakness. The aide stopped the transfer and sought help from a nurse. The charge nurse, an LPN, responded and assisted in transferring the resident back to bed, then to a wheelchair using the Hoyer lift. The LPN checked the resident for pain, bruising, or deformity, and found none at that time. No immediate documentation or assessment by a registered nurse was completed following the incident, and no accident/incident report was initiated. The following day, the resident complained of pain, and swelling and redness were observed, leading to further evaluation and discovery of a left tibia fracture. Interviews with facility staff confirmed that the incident was not documented as required by facility policy, which mandates that a licensed nurse or supervisor complete and document an evaluation of the resident's condition after an incident. The nursing supervisor and LPN both acknowledged that a nursing assessment and note should have been completed, and the administrator and DNS agreed that the event constituted an incident requiring such documentation.
Failure to Protect Resident's Controlled Medication from Misappropriation
Penalty
Summary
A controlled medication, Ativan, prescribed for a resident with diagnoses including cerebral infarction, anxiety, and depressive disorder, was found missing from the facility. The medication, delivered in a bubble pack containing thirty tablets, was last verified as present during a shift change count by two nurses. Subsequently, it was discovered that twenty-nine tablets were missing. Documentation and interviews revealed that the nurse responsible for the 3-11PM shift left the medication cart keys on top of the cart and proceeded to another unit, while the incoming 11PM-7AM nurse did not immediately take possession of the keys or access the cart, despite both nurses having signed off on the controlled medication count. The incident was reported to the Director of Nursing and the Drug Enforcement Agency, and an internal investigation was conducted, including audits and staff interviews. The facility's abuse policy defines misappropriation of resident property as the wrongful use of a resident's belongings without consent. The investigation was unable to determine how the Ativan went missing, but the failure to maintain proper control and accountability of the medication, as well as lapses in the handoff process and medication cart security, led to the loss of the resident's controlled medication. The resident was alert and oriented at the time, with a care plan in place for medication administration and monitoring.
Failure to Timely Report Missing Controlled Medication
Penalty
Summary
The facility failed to report the misappropriation of a resident's controlled medication, Ativan, to the state agency within the required two-hour timeframe. A resident with diagnoses including cerebral infarction, anxiety, and depressive disorder was prescribed Ativan 1 mg as needed for anxiety. On a specified date, it was discovered that 29 tablets of Ativan were missing from the resident's medication supply. The missing medication was identified during a shift change count, and subsequent investigation revealed discrepancies in the medication count process and handling of the medication cart keys by nursing staff. The incident was reported to the Director of Nursing, but there was a delay in notifying the Administrator and external authorities. The Administrator was informed of the missing medication two days after it was reported to the Director of Nursing, and the incident was not reported to the Department of Consumer Protection, Drug Enforcement Division, Department of Public Health, or local law enforcement until four days after the initial discovery. The facility's abuse policy requires immediate reporting of alleged violations, including misappropriation of resident property, to the Administrator and Director of Nurses. However, the delay in reporting the missing medication constituted a failure to comply with this policy and regulatory requirements.
Failure to Timely Notify Provider of Resident's Change in Condition Leading to Hospitalization
Penalty
Summary
The facility failed to notify the healthcare provider in a timely manner regarding a resident's change in condition, which ultimately led to a hospitalization. The resident, who had a history of hemiplegia, hemiparesis, and dysphagia following a cerebral infarction, was documented as having diminished lung sounds upon admission. Over several days, nursing notes recorded the development and progression of respiratory symptoms, including a non-productive cough, crackles on auscultation, and later a productive cough with moderate white secretions. Despite these documented changes in respiratory status from 8/30/24 through 9/2/24, there was no evidence that the provider was notified during this period. On 9/3/24, the resident exhibited further decline, including altered mental status, increased confusion, a low-grade fever, and a decreased oxygen saturation level. At this point, the provider was notified, and the resident was transferred to the emergency department. Hospital records indicated that the resident arrived with hypoxemia, fever, and tachycardia, and was subsequently diagnosed with probable aspiration pneumonia and treated with antibiotics. Interviews with facility staff and the APRN confirmed that the expectation was for immediate provider notification upon the initial observation of a productive cough and abnormal lung sounds, which did not occur. Facility policy required that any change in condition be promptly communicated to the provider, the resident, and the family or responsible party. The review of documentation and staff interviews revealed that this policy was not followed, as the provider was not informed of the resident's respiratory changes until several days after the initial symptoms were observed. This delay in notification was confirmed by both the APRN and the previous DNS, who stated that provider notification should have occurred immediately upon the identification of the change in lung sounds and cough.
Failure to Update Care Plan and Communicate Resident Preferences After Grievance
Penalty
Summary
A resident with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, anxiety, and gait abnormalities, who was cognitively intact, required moderate assistance with activities of daily living such as toileting, bathing, and dressing. The resident submitted a grievance requesting more frequent care checks, prompt changing of soiled linens, and specific attention to scalp and jawline hygiene during bathing due to dry skin. Although the facility received these care requests and held a care plan meeting with the interdisciplinary team, the resident, and the resident's spouse to discuss the concerns, the care plan and care card were not updated to reflect the resident's preferences and requests. Additionally, there was no documentation provided to show that staff had been educated on the resident's specific care concerns and preferences. The facility's Resident Rights policy requires prompt efforts to resolve grievances and reasonable accommodation of individual needs and preferences, but the failure to update the care plan and care card, as well as the lack of staff education, demonstrated noncompliance with these requirements.
Failure to Provide Fall Prevention Measures with New Bed Equipment
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a new piece of equipment, specifically a mattress and bed frame, had the necessary fall prevention measures in place for a resident with a history of hemiplegia, hemiparesis, and mobility impairments. The resident required moderate assistance for bed mobility and transfers and was identified as being at risk for falls due to left side weakness and use of psychotropic medications. The care plan included interventions such as keeping the bed in a low position and using non-skid footwear, as well as the use of bolsters to prevent falls from bed. After an initial fall, a mattress with bolsters was ordered, but when a larger replacement mattress and bed frame were subsequently ordered, bolsters were not included or specifically ordered for the new equipment. The facility administrator did not verify whether the new mattress came with bolsters and assumed that pillows placed under the sheet would suffice as a preventive measure. As a result, the resident experienced another fall from bed, sustaining left shoulder pain, though without serious injury.
Medication Administration Errors Due to Transcription and Supply Issues
Penalty
Summary
The facility failed to administer medications in accordance with physician orders for a resident diagnosed with essential tremor. The hospital discharge orders specified the administration of Propranolol 60 mg 24-hour capsule daily, but the facility administered a non-extended-release Propranolol HCL oral tablet 60 mg instead. This discrepancy was identified when the resident was being discharged and reported the error. The Director of Nursing Services (DNS) confirmed that the error was due to a transcription mistake, and the incorrect medication was sourced from the facility's emergency supply. Additionally, the facility did not administer Bupropion HCL ER (XL) 150 mg oral tablet extended release as ordered by the physician. The medication was omitted because it had not been received from the pharmacy, and there was none available in the facility's emergency supply. These incidents highlight a failure in the medication administration process, specifically in transcribing and ensuring the availability of prescribed medications.
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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 Storrs Mansfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vanderman Place | 5.5 mi | ★★★★★ | 0 | 0 |
| Saint Josephs Living Center, Inc. | 6.4 mi | ★★★★★ | 2 | 0 |
| Douglas Manor | 7.6 mi | ★★★★★ | 7 | 0 |
| Woodlake At Tolland | 10 mi | ★★★★★ | 20 | 0 |
| Complete Care At Fox Hill | 10.5 mi | ★★★★★ | 12 | 0 |
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