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 Arbors At Mifflin during CMS and state inspections, most recent first.
A resident with multiple diagnoses, including a UTI and infection of a prosthetic hip joint, did not receive prescribed antibiotics as ordered. The facility failed to notify the physician about the unavailability of the medication. The DON confirmed the medication was not administered on several occasions, and there was no notification to the physician, contrary to the facility's policies.
The facility failed to datemark potentially hazardous food items in the walk-in cooler and maintain kitchen utensils in a safe and sanitary condition. Undated food items and unsanitary utensils were found during an observation, which the Dietary Manager confirmed were not in compliance with the facility's policies.
The facility failed to ensure that residents' advance directives were clearly identified in their medical records. One resident's record contained both Full code and undated DNR documents, while another resident's change from Full code to DNR was not updated in the physician orders. The DON confirmed these discrepancies and acknowledged the lack of immediate notification and updating protocol.
The facility failed to provide the correct Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and Notice of Medicare Non-Coverage (NOMNC) forms for two residents. One resident's forms lacked an estimated cost and had an incorrect QIO phone number, while another resident did not receive the required SNFABN form.
The facility failed to ensure proper respiratory care for three residents by not having physician orders for oxygen use and not safely storing oxygen tanks. One resident had unsecured oxygen tanks in their room, another had an unsecured tank near the doorway, and a third resident was using oxygen without any physician orders in their medical record.
A resident with schizoaffective disorder and other diagnoses experienced significant medication errors due to duplicate orders for loxapine. The resident's MAR showed multiple instances of missed doses and duplicate administrations, and the facility failed to notify the provider about the missing doses, contrary to their medication management policy.
The facility failed to follow the menu and provide appropriate food to three residents, resulting in missing items on their meal trays. This was confirmed by staff and affected residents with specific dietary needs and preferences.
A facility failed to implement appropriate transmission-based precautions for a resident with chronic clostridium difficile infection. Staff were observed not following infection control protocols, such as wearing PPE and performing hand hygiene, despite physician's orders and the facility's policy. The DON confirmed the need for contact isolation, but staff continued to neglect proper measures.
Failure to Administer Antibiotics and Notify Physician
Penalty
Summary
The facility failed to ensure that antibiotics were administered as ordered and did not notify the physician when the antibiotics were unavailable for administration. This deficiency affected a resident who was admitted with diagnoses including a urinary tract infection, infection of a prosthetic hip joint, osteoarthritis, and major depressive disorder. The resident required assistance with activities of daily living and had intact cognition. The physician had ordered Doxycycline Hyclate 100 mg to be administered orally every morning and at bedtime for cellulitis, but the medication was not administered on several occasions. The Medication Administration Record showed that the antibiotic was not given on specific dates, and the facility's progress notes revealed no notifications to the physician or nurse practitioner about the missed doses. The Director of Nursing confirmed the failure to administer the medication and the lack of notification to the physician. The facility's policies on medication administration and notification of changes were not followed, as medications should be administered as ordered, and any issues should be documented and communicated to the physician for further instructions.
Failure to Datemark Food and Maintain Sanitary Kitchen Utensils
Penalty
Summary
The facility failed to datemark potentially hazardous food items in the walk-in cooler and maintain kitchen utensils in a safe and sanitary condition. During an observation of the kitchen, it was found that two blocks of sliced orange cheese, an open block of ham, an open block of turkey breast, an open pork loin, and a large box of colored eggs were stored undated. The Dietary Manager confirmed that these items were not dated and provided information on when some of the items were last handled. The facility's policies on food storage and receiving were reviewed and indicated that all foods should be labeled and dated, which was not adhered to in this instance. Additionally, the facility failed to maintain kitchen utensils in a sanitary condition. Observations revealed two rubber spatulas that were chipped and scored, stored in the clean kitchen utensil storage drawer. Another used spatula covered in a yellow butter-like substance was found among clean utensils. Further observation found another spatula with a torn corner and scoring, stored next to a puree machine. The Dietary Manager confirmed these utensils were not usable and took action to remove them. The facility's equipment policy requires all foodservice equipment to be clean, sanitary, and in proper working order, which was not followed in these cases.
Failure to Clearly Identify Advance Directives in Medical Records
Penalty
Summary
The facility failed to ensure that residents' advance directives were clearly identified in their medical records. For Resident #36, the electronic medical record indicated a Full code status, but the paper chart contained both a Full code document and an undated Do Not Resuscitate (DNR) document. This discrepancy was confirmed by the Director of Nursing (DON), who acknowledged that the advance directives were not clearly identified in the medical record. For Resident #129, the medical record initially indicated a Full code status, but the paper chart contained a DNR form dated later. The DON confirmed that Resident #129 had changed from Full code to DNR, but the physician orders had not been updated to reflect this change. The facility's protocol did not include immediate notification and updating of the physician orders upon a change in code status. The review of the facility admission packet revealed that residents are provided with forms to indicate their CPR preferences upon admission and during quarterly evaluations.
Failure to Provide Correct SNFABN and NOMNC Forms
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) for two residents, and the Notice of Medicare Non-Coverage (NOMNC) was not filled out correctly for one of them. Resident #16, who was admitted with chronic obstructive pulmonary disease (COPD) and schizoaffective disorder, received skilled services under Medicare Part A but remained in the facility after the skilled services ended. The SNFABN form for Resident #16 did not include an estimated cost, and the NOMNC form had an incorrect telephone number for the Quality Improvement Organization (QIO). This was confirmed by the Social Service Director (SSD) during an interview, who acknowledged the errors in the forms provided to Resident #16. Resident #43, who was readmitted with diagnoses including paranoid schizophrenia, transient ischemic attack (TIA), and type II diabetes mellitus with diabetic neuropathy, also received skilled services under Medicare Part A. The facility initiated the discharge from Medicare Part A before the benefit days were exhausted and provided a NOMNC form but failed to provide a SNFABN form to the resident or their representative. The Business Office Manager (BOM) and the Social Service Director (SSD) confirmed that the SNFABN form should have been issued but was not, indicating a lapse in the facility's process for issuing these forms correctly.
Failure to Ensure Proper Respiratory Care and Oxygen Storage
Penalty
Summary
The facility failed to ensure proper respiratory care for three residents by not having physician orders for oxygen use and not safely storing oxygen tanks. Resident #17, diagnosed with COPD, congestive heart failure, and anxiety, had an order for continuous supplemental oxygen but was found with two unsecured metal portable oxygen tanks in their room. Similarly, Resident #69, diagnosed with COPD, chronic respiratory failure, morbid obesity, and obstructive sleep apnea, had an order for continuous supplemental oxygen but was observed with an unsecured metal portable oxygen tank near the doorway of their room. Both instances were verified by nursing staff who then removed the unsecured tanks. Resident #41, diagnosed with pneumonia and heart disease, was admitted to the facility and required oxygen use. However, there were no physician orders for oxygen use in the resident's medical record from admission until the time of the survey. The resident was observed using oxygen via nasal cannula connected to an oxygen concentrator, which also had an undated humidification bottle with tubing not attached to anything. The Director of Nursing confirmed the absence of oxygen orders in the resident's chart upon admission and re-admission, despite the resident using oxygen.
Failure to Ensure Resident Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Resident #16, who had diagnoses including schizoaffective disorder, bipolar disorder, depression, and muscle weakness, was affected by this deficiency. The resident had intact cognition and was receiving antipsychotic medications daily. The medical record revealed two active and open-ended orders for loxapine, one for 50 mg and another for 10 mg, which led to confusion and errors in medication administration. The resident's Medication Administration Record (MAR) showed multiple instances where the resident either did not receive the medication or received both strengths of the medication on the same day. The facility's progress notes indicated that the medication was frequently unavailable from the pharmacy, but there was no evidence that the provider was notified about the missing doses. Interviews with the Unit Manager and the Director of Nursing confirmed that the resident should have only been on loxapine 150 mg once nightly and that the duplicate orders were an error. They also verified that the MAR contained evidence of both duplicate administrations and omissions of the medication. The facility's policy on medication management and administration required documentation of medication administration and reasons for any missed doses, as well as notification to the physician for further orders if a medication was not available. However, these procedures were not followed, leading to the significant medication error for Resident #16.
Failure to Follow Menu and Provide Appropriate Food
Penalty
Summary
The facility failed to follow the menu and provide residents with the appropriate food as indicated on their meal tickets. This deficiency affected three residents. Resident #28, who has Alzheimer's disease and type II diabetes, did not receive the marinated cucumber salad listed on their lunch meal ticket. This was confirmed by a State tested Nursing Aide (STNA) and the Dietary Manager. Resident #39, who has hypertensive heart disease and chronic kidney disease, also did not receive the marinated cucumber salad listed on their lunch meal ticket. This was confirmed by a Dietary Aide and the Dietary Manager. Both residents did not have any documented dislikes for cucumbers or vegetables in their food preference lists. Resident #134, who has multiple sclerosis and type II diabetes, did not receive the rotisserie chicken thigh, garlic potato wedges, sliced carrots, and sugar cookie listed on their dinner meal ticket. The resident confirmed that they never indicated they did not want the food and that they liked all the items except the sugar cookie. This was confirmed by the Activities Director, who later provided the resident with another plate of food that included a dinner roll, which was against the resident's preference list stating 'No Bread.' The facility's policy requires nursing personnel to ensure residents are served the correct food tray, but this was not followed in these instances.
Failure to Implement Proper Infection Control Measures
Penalty
Summary
The facility failed to ensure appropriate transmission-based precautions (TBP) were implemented for a resident diagnosed with enterocolitis due to clostridium difficile and severe protein-calorie malnutrition. Despite having physician's orders for contact precautions and active treatment with vancomycin, staff were observed not following the required infection control protocols. Signage outside the resident's room incorrectly indicated airborne and droplet isolation precautions, and multiple staff members were observed entering and exiting the room without wearing personal protective equipment (PPE) or performing proper hand hygiene. Interviews with staff revealed confusion and inconsistency regarding the resident's isolation status and the necessary precautions. The Director of Nursing (DON) confirmed that the resident should be under contact isolation precautions due to chronic clostridium difficile infection and verified that the incorrect signage was removed. However, observations showed that staff continued to neglect proper infection control measures, such as wearing gowns and using designated biohazard bags for soiled materials. The facility's policy on managing C. difficile infection, which mandates the use of gloves and gowns and handwashing with soap and water, was not adhered to by the staff, leading to a deficiency in infection prevention and control.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 85 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mansfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Grove Manor | 0 mi | ★★★★★ | 4 | 0 |
| Jag Healthcare Mansfield | 4.3 mi | ★★★★★ | 0 | 0 |
| Winchester Terrace | 4.6 mi | ★★★★★ | 3 | 0 |
| Liberty Nursing Center Of Mansfield | 5 mi | ★★★★★ | 0 | 0 |
| Crystal Care Center Of Mansfie | 5.4 mi | ★★★★★ | 0 | 0 |
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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.