Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Mansfield Nursing Center during CMS and state inspections, most recent first.
Failure to notify physician and DON of acute respiratory decline: An LPN observed a resident with labored breathing, accessory muscle use, and an O2 sat of 60% on room air during med pass. Oxygen was started and the sat improved, but the physician was not contacted immediately and the DON was not notified until EMS was at the facility.
Failure to Reassess Bed Assist Rails: A resident with hemiplegia, hemiparesis, and limited ROM was observed in bed without assist rails after the rails had been removed during a hospital stay. The resident and RP requested the rails be returned, and staff confirmed the resident used the rails for turning and mobility assistance and that a bed rail assessment should be completed after a change in status or return from discharge.
Failure to Provide Transfer/Discharge Notices and Ombudsman Notification: The facility did not provide a resident or RP written transfer/discharge notice with the reason for transfer, effective date, location, appeal rights, and bed-hold details for one resident sent to the ED, and it did not document written LTC Ombudsman notification for two residents who were transferred or discharged. The DON and Social Services stated written bed-hold notices were not being provided, and the Administrator confirmed the Ombudsman had not been notified in writing.
Failure to Implement EBP for Three Residents Three residents with wounds, a Foley catheter, or surgical staples were observed without EBP signage outside their rooms and without gowns, gloves, or ABHR readily available. Staff were seen providing ADL care using gloves only, and one resident reported staff had not worn a gown during baths or turning. One resident also lacked an EBP order despite having wounds and staples.
Respiratory care was not provided consistent with facility policy for two residents. One resident with chronic respiratory failure and SOB had oxygen tubing that was not changed weekly as ordered, and an LPN confirmed it was overdue. Another resident with COPD had oxygen in use, but there was no oxygen sign on the room door and the respiratory mask was left uncontained on the bedside table instead of being stored in a plastic bag when not in use.
Controlled Drug Record Not Reconciled for Lorazepam: A resident’s lorazepam count on Medication Cart A was not maintained accurately. The Controlled Drug Record showed 48 doses remaining after the last documented dose, but the blister pack contained 47 doses. An LPN said she failed to complete the Controlled Drug Record for the morning dose and acknowledged the discrepancy; the DON stated narcotics should be documented on both the MAR and hard copy for verification.
A resident's funds were misappropriated by a CNA who transferred money from the resident's bank account to her own without consent. The resident, who was cognitively intact, reported the incident after discovering the missing funds. An internal investigation confirmed the unauthorized transfer, and the facility reported the incident to the police.
The facility did not post the most recent survey results in a location accessible to residents, family, or others. Observations and an interview with the administrator confirmed the absence of the survey results in an easily accessible place.
The facility failed to ensure proper use and documentation for bed rails for four residents, lacking necessary assessments, physician orders, and informed consents. Residents with significant mobility and cognitive impairments were observed with bed rails installed without required documentation, as confirmed by staff interviews.
The facility failed to monitor two residents for side effects from antidepressant and antianxiety medications. One resident was not monitored for side effects from an antidepressant, despite having a care plan requiring such monitoring. Another resident, with multiple diagnoses and prescribed several medications, was also not monitored for side effects. The Director of Nursing acknowledged these oversights.
A facility failed to monitor a resident for edema while the resident was on a diuretic medication. The resident, with heart failure and diabetes, was prescribed Chlorthalidone. However, the medication administration record showed no monitoring for edema, which was acknowledged by the DON.
Failure to Notify Physician and DON of Resident’s Acute Respiratory Decline
Penalty
Summary
The facility failed to immediately notify the resident’s physician and/or the DON of a significant change in condition for one resident who developed severe shortness of breath. During med pass, an LPN observed the resident with labored breathing and assessed an oxygen saturation of 60% on room air. Oxygen was applied at 2 liters per minute by nasal cannula, and the saturation increased to 90%, but the physician was not contacted until about 8:00 a.m., when a message was left at the doctor’s office. The physician later returned the call and ordered transfer to the emergency room for evaluation and treatment related to the resident’s use of accessory muscles and oxygen saturation remaining at 90-91% on oxygen. The facility’s policy stated that the charge nurse would notify the attending physician immediately if the resident’s condition was deemed an emergency and that the doctor should be called immediately when pulse oximetry was 90% or less. During interview, the LPN stated she observed the resident’s labored breathing, low oxygen saturation, and use of accessory muscles, started oxygen, and then called the physician’s office. The DON stated she was not notified of the resident’s change in condition until EMS was at the facility and said she should have been notified.
Failure to Reassess Bed Assist Rails
Penalty
Summary
The facility failed to accommodate the needs and preferences of Resident #8 by not ensuring the resident was reassessed for the use of assist rails. Resident #8 was admitted with a readmission on 07/28/2025 and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and lack of coordination. The Quarterly MDS dated 06/08/2025 showed a BIMS score of 13/15, indicating intact cognition, and documented limited range of motion in both upper and lower extremities on one side. During observation on 08/11/2025, the resident was resting in bed without assist rails. The resident stated the facility had removed the bed rails while she was away at the hospital and that she and her RP had requested the rails be put back. Staff interviews confirmed the resident used bed rails to turn and assist with mobility, had requested them to be returned, and that bed rail assessment should be completed quarterly, upon change in status, return from discharge, admission, or sooner if necessary.
Failure to Provide Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide written notice to the resident and/or the resident representative that specified the reason for transfer, the effective date, the location, the statement of appeal rights, and the duration of the bed-hold policy for 1 of 2 residents reviewed for transfer/discharge. Review of the facility’s Bed Hold Prior to Transfer policy showed that written information was to be provided to the resident and/or resident representative regarding bed hold before transfer, including the duration of any state bed-hold and the facility’s bed-hold policy. However, the record for Resident #74, who was admitted on 03/11/2021 with diagnoses including Alzheimer’s disease, major depressive disorder, and anxiety, showed that the resident was sent to the local ED on 06/20/2025, and the record did not contain written notice of transfer/discharge provided at the time of transfer. The facility also failed to provide documented evidence that the State’s Long-Term Care Ombudsman was notified in writing of discharges for 2 of 2 residents reviewed for discharge requirements. Resident #76, admitted on 06/17/2025 with diagnoses including COPD, major depressive disorder, chronic respiratory failure, and atrial fibrillation, was discharged home, but the record did not show written notification to the Ombudsman. During interviews, the DON stated nursing does not provide a written bed-hold notice to the resident or resident representative at the time of discharge or transfer and was not aware one needed to be sent with the resident. Social Services stated a written bed-hold notice was not being provided at the time of transfer, and the Administrator and Social Services confirmed the Ombudsman had not been notified in writing of Resident #74’s transfer or Resident #76’s discharge.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure infection control measures were in place for three sampled residents requiring enhanced barrier precautions (EBP). The report states that clear signage was not posted outside the rooms of Residents #10, #13, and #79 to identify the precautions, required PPE, and high-contact care activities requiring gown and gloves. It also states that gowns, gloves, and alcohol-based hand rub were not available outside those rooms, and that Resident #79 did not have an order for EBP despite having wounds and staples. Resident #10 was admitted with diagnoses including acute kidney failure, benign prostatic hyperplasia, liver cell carcinoma, viral hepatitis C, adult failure to thrive, and COPD. Physician orders included wound care for a stage 2 sacral wound, urinary catheter care every shift, and EBP related to a Foley catheter. Observations showed Resident #10 in bed with a Foley catheter, but no EBP signage and no gowns, gloves, or alcohol-based hand rub outside the room. Staff were observed providing ADL care using gloves only, and the resident reported staff had not been wearing a gown during baths or turning. Resident #13 had diagnoses including atrial fibrillation, anxiety disorder, pain, right above-knee amputation, and a third-degree burn of the left lower leg. Physician orders included wound care to the left lower leg and stump care, with EBP related to wounds. Observations showed Resident #13 in a wheelchair and later in the room without EBP in place, and the resident reported staff wore gloves but no gowns. Resident #79 was admitted with diagnoses including intracerebral hemorrhage, aneurysm, obstructive hydrocephalus, convulsions, and hemiplegia/hemiparesis. Physician orders included monitoring of abdominal and head surgical sites with staples, but no EBP order was found. Observations showed staples on the scalp and behind the ear, the resident reported an abdominal site, and staff provided ADL care using gloves only while no EBP signage or PPE was present outside the room.
Respiratory Equipment Not Managed Per Policy
Penalty
Summary
Respiratory care was not provided consistent with facility policy for two residents reviewed. The facility’s Respiratory Equipment-Infection Control Guidelines required oxygen cannula or mask and tubing to be dated when put in use and changed at least weekly, and required equipment, administration sets, and tubing to be covered when not in use. The facility’s Oxygen Administration procedure also required an “Oxygen in Use” sign on the outside of the room entrance door. Resident #60 had diagnoses including chronic respiratory failure with hypoxia and shortness of breath and had an order for oxygen at 2L via nasal cannula as needed for shortness of breath or oxygen saturation less than 95%, along with an order to change and date oxygen tubing every week on Friday during day shift. On observation, the resident’s oxygen tubing was dated 08/02/2025, and an LPN confirmed the tubing should have been changed weekly but was not. Resident #77 had diagnoses including COPD and orders for Ipratropium-albuterol inhalation three times daily and oxygen at 2L. On observation, the resident was lying in bed with oxygen via nasal cannula in place, but there was no oxygen in use sign on the room entrance door, and the resident’s respiratory mask was stored uncontained on the bedside table. An LPN confirmed the nebulizer mask should have been stored in a plastic bag when not in use and was not.
Controlled Drug Record Not Reconciled for Lorazepam
Penalty
Summary
The facility failed to ensure the Controlled Drug Record was maintained and reconciled for one medication cart. Review of the facility’s Controlled Substances policy showed that controlled substances obtained from a non-automated medication cart or cabinet are to be recorded on the designated usage form, and that the Controlled Drug Record is a permanent medical record document used with the MAR for documenting patient-specific narcotics dispensed from the pharmacy. During review of Medication Cart A, an inaccurate remaining dose count was found for a resident’s lorazepam 0.5 mg oral tablet on the Controlled Drug Record. The resident had a physician order for lorazepam 0.5 mg, one-half tablet by mouth twice daily. The Controlled Drug Record showed the last documented dose was given at 8:00 p.m. with 48 doses remaining, but the blister pack contained 47 doses remaining. An LPN stated she failed to complete the Controlled Drug Record for the 8:00 a.m. dose and acknowledged the discrepancy in the blister pack count. The DON stated narcotics should be documented with two different methods, the MAR and hard copy for verification.
Misappropriation of Resident Funds by Staff
Penalty
Summary
The facility failed to protect a resident from misappropriation of property and exploitation by staff. A Certified Nursing Assistant (CNA) transferred money from the resident's bank account to her personal account without the resident's consent. The resident, who was cognitively intact, reported the incident to the facility administrator after discovering the missing funds during a bank visit with her aunt. The facility's internal investigation revealed that the CNA's mother, who also worked at the facility, facilitated the transaction by offering her daughter's account for the transfer. The resident denied requesting the use of the CNA's account for any financial transactions. The facility administrator confirmed the unauthorized transfer of $250 to the CNA's account and reported the incident to the police. The facility's abuse prevention policy clearly states that residents should be free from exploitation and misappropriation of property. Despite this policy, the staff involved acted against the resident's rights, leading to the deficiency. The facility's administrator took immediate action by suspending the involved staff and initiating an investigation, but the money was not recovered at the time of the report.
Failure to Post Survey Results in Accessible Location
Penalty
Summary
The facility failed to ensure that the most recent survey results were posted in a location that was readily accessible to residents, family members, or anyone wishing to review them. On the morning of August 12, 2024, observations were made that did not reveal the presence of the most recent survey results in an accessible location. This was further confirmed during an observation with the facility's administrator, who acknowledged that the survey results were not posted in a place that was easily available for review. During an interview later that morning, the administrator confirmed that the survey results should have been posted for residents, family, and others to review.
Failure to Ensure Proper Use and Documentation for Bed Rails
Penalty
Summary
The facility failed to ensure the correct use and maintenance of bed rails for four residents, as evidenced by the lack of necessary assessments, physician orders, and informed consents. Resident #8, who has functional quadriplegia and a history of falling, was observed with bed rails in place without a physician's order, risk assessment, or signed consent. Interviews with staff confirmed the absence of these critical documents. Similarly, Resident #10, with severely impaired cognition and total dependence for transfers, was found to have bed rails installed without the required physician's order, risk assessment, or consent. Observations confirmed the presence of bed rails, and staff interviews corroborated the lack of documentation. Resident #13 and Resident #37 also had bed rails installed without physician orders or consents. Both residents have significant mobility and cognitive impairments, requiring assistance for bed mobility and transfers. Observations and staff interviews confirmed the use of bed rails and the absence of necessary documentation, highlighting a systemic issue in the facility's management of bed rail safety protocols.
Failure to Monitor Medication Side Effects
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free of unnecessary medications, specifically for two residents out of five reviewed. Resident #13 was not monitored for side effects while receiving an antidepressant medication, despite having a comprehensive care plan that required assessment for adverse reactions and documentation of side effects. The resident's August 2024 Medication Administration Record did not show any monitoring for side effects, which was acknowledged by the Director of Nursing during an interview. Similarly, Resident #39 was not monitored for side effects from both antidepressant and antianxiety medications. The resident had multiple diagnoses, including cognitive communication deficit, generalized anxiety disorder, and major depressive disorder, and was prescribed several medications, including Lorazepam, Duloxetine, Buspirone, and Divalproex Sodium. However, the August 2024 Medication Administration Record did not reveal any monitoring for side effects, which was also acknowledged by the Director of Nursing.
Failure to Monitor Resident for Edema While on Diuretic
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, the facility did not monitor a resident for edema while the resident was receiving a diuretic medication. The resident, who was admitted with diagnoses including heart failure and type 2 diabetes mellitus with diabetic neuropathy, had a physician's order for Chlorthalidone, a diuretic, to be administered daily. However, a review of the resident's medication administration record for August 2024 showed no evidence of monitoring for edema. During an interview, the Director of Nursing acknowledged that the resident was not monitored for edema as required.
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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 Mansfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Desoto Retirement & Rehab Ctr, Llc | 1.6 mi | ★★★★★ | 2 | 0 |
| Green Meadow Haven | 20.2 mi | ★★★★★ | 6 | 0 |
| Village Health Care At The Glen | 24.9 mi | ★★★★★ | 3 | 0 |
| Heritage Manor South | 25 mi | ★★★★★ | 4 | 0 |
| Live Oak | 25 mi | ★★★★★ | 0 | 0 |
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