Below 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 Jag Healthcare Mansfield during CMS and state inspections, most recent first.
The facility did not document required quarterly QAA meetings with all mandated members present, as sign-in sheets were missing or incomplete for several quarters. Key committee members, such as the Medical Director, DON, and Infection Preventionist, were absent from some meetings, and the Administrator confirmed these lapses. This deficiency had the potential to affect all residents in the facility.
A resident with severe cognitive impairment and total dependence for mobility had personal items go missing, including blankets, clothing, and stuffed animals. Despite reports from the family and other residents about missing items, staff did not document, investigate, or follow up as required by facility policy. Laundry staff frequently received informal reports of missing clothing but discarded notes after searching, and no formal grievance or resolution process was followed, leading to ongoing unresolved complaints among residents.
Staff failed to provide timely wound care and assessments for two residents with chronic wounds, as wound dressings were not dated and weekly wound evaluations were not completed as required. Additionally, a resident receiving hospice care did not receive pain medication during a painful catheter procedure, and staff did not address significant changes in the resident's skin condition. These deficiencies were confirmed through observations, interviews, and record reviews.
A resident with complex medical needs and an indwelling catheter experienced delays in assessment and intervention after removing her catheter and showing signs of infection. Staff did not promptly notify the physician or hospice of significant changes, failed to follow up on lab results indicating a UTI, and did not adhere to proper infection control during catheter reinsertion. These failures in catheter care and communication had the potential to affect other residents with catheters.
Two residents experienced significant medication errors when staff failed to obtain daily weights and administer as-needed Lasix as ordered, and an RN administered insulin without priming the pen as required. These actions were not in accordance with physician orders, manufacturer instructions, or facility policy, and similar errors could potentially affect other residents receiving insulin.
The facility failed to ensure required PPE was available and used for residents on contact precautions, did not implement enhanced barrier precautions, and did not screen residents for tuberculosis as required. This affected four residents, including those with significant wounds and multiple infections.
The facility failed to ensure that a resident was offered an annual influenza vaccination as required. Despite the resident being cognitively intact and having multiple diagnoses, the last documented influenza vaccination was from the previous year, and there was no record of the resident being offered or declining the vaccination during the past influenza season. The facility's policy mandates annual offering and documentation of the influenza vaccine, which was not adhered to in this case.
The facility failed to offer the COVID-19 vaccination or document the vaccination status for three residents, despite their cognitive ability to consent. This deficiency was confirmed through staff interviews and medical record reviews.
The facility experienced Immediate Jeopardy due to financial mismanagement, resulting in unpaid bills to vendors and potential interruptions in essential services for residents. Delayed payments affected therapy services, food vendors, staffing agencies, and utility providers. Financial instability was worsened by a low census, staff turnover, and challenges in completing necessary assessments for billing. Key personnel, including the Administrator, CEO, and Business Office Manager, cited a lack of oversight and accountability. The Board of Directors was aware but did not take decisive action. Residents were directly impacted, with some requesting discharge due to the lack of therapy services and essential supplies. The deficiency affected therapy, food delivery, staffing, and communication services.
The facility failed to ensure resident mail was delivered unopened and that residents had access to a private working telephone. The CEO admitted to opening resident mail, and the phone system was non-functional due to an outstanding balance, preventing residents from making or receiving calls.
The facility failed to maintain sufficient staffing levels due to a hostile work environment and financial issues, leading to delayed resident care and significant staff turnover. The facility was unable to continue using agency staff due to non-payment, resulting in numerous unfilled nursing shifts and concerns about timely resident care.
The facility failed to ensure a full-time DON, affecting all 56 residents. The previous DON worked limited hours before the facility was left without a DON for over three months. An interim DON was brought in but requested a new assignment due to discomfort with the CEO's questioning. The facility had no plan to secure a new DON after the interim DON's contract ended.
The facility failed to provide necessary rehabilitative services, including physical and speech therapy, due to overdue payments to the therapy vendor. This affected 19 residents, some of whom requested discharge due to the lack of services. As of mid-April, the facility had not secured a new therapy provider.
The facility failed to ensure an effective governing body responsible for financial management, leading to significant cash-flow problems and service interruptions. The Administrator did not handle financial aspects, and the CEO and Board of Directors were aware of payment delays to vendors, affecting essential services for all 56 residents.
The facility failed to ensure continuous evaluations to verify financial obligations were met, potentially disrupting resident care and services. The Medical Director was unaware of financial issues, and the CEO admitted that no QAPI meeting was initiated to address the cash flow problem caused by management changes. The facility owed $271,963.63 to various vendors, leading to service interruptions.
The facility failed to provide quarterly statements of resident trust fund accounts to eighteen residents. The Administrator confirmed the oversight, and interviews with two residents corroborated the deficiency. This issue was investigated under Complaint Number OH00151839.
The facility failed to disperse resident fund accounts within 30 days for seven discharged residents, as required by policy. Interviews confirmed that trust fund monies were not returned to residents or their representatives within the stipulated timeframe, affecting residents with various medical conditions including Alzheimer's disease, major depressive disorder, and dementia.
The facility failed to ensure that residents were provided with and signed the necessary admission documentation, including the Consent to Treatment and Other Acknowledgements form and the Nursing Home Admission Agreement. This affected 41 residents, resulting in the facility not having consent to bill Medicare/Medicaid or to treat the residents.
The facility failed to ensure timely and required initial comprehensive assessments for seven residents, affecting their care. Interviews confirmed that the assessments were either still in progress or overdue, indicating a significant lapse in compliance.
The facility failed to complete quarterly comprehensive assessments for four residents, including those with chronic respiratory failure, COPD, Parkinson's disease, and end-stage renal disease. This was confirmed through interviews with the BOM and Administrator.
The facility failed to ensure a resident's discharge summary included the reconciliation of medications upon discharge. The resident's wife reported that the facility handed her paperwork to sign without going over the discharge part, including the medication list. This deficiency was confirmed by the Administrator and investigated under Complaint Number OH00151839.
A resident with severe cognitive impairment and specific dietary orders did not receive ice cream with meals from 04/11/24 to 04/15/24 because the facility ran out of ice cream and was unable to purchase more due to a maxed-out credit card. The Dietary Kitchen Manager confirmed the issue and stated that ice cream would be delivered on 04/17/24.
Failure to Hold Required QAA Meetings with All Mandated Members
Penalty
Summary
The facility failed to hold required Quality Assessment and Assurance (QAA) meetings at least quarterly with all mandated members present, as evidenced by a review of QAA meeting sign-in documentation, staff interviews, and facility policy. There was no documentation of QAA meetings for the first, second, and third quarters of 2024. For the fourth quarter of 2024, while a meeting was documented, there was no sign-in sheet to confirm the attendance of all required members. Additionally, meetings held in early 2025 were missing attendance from key members, including the Medical Director, Director of Nursing, and Infection Preventionist. The Administrator confirmed during an interview that there was no documentation of quarterly QAA meetings prior to the fourth quarter of 2024 and that not all required members were present for subsequent meetings. The facility's policy specifies that the QAA committee must include the administrator (or designee), director of nursing services, medical director, infection preventionist, and representatives from various departments as needed, and that meetings must occur at least quarterly. The lack of proper documentation and attendance had the potential to affect all residents, with a facility census of 57 at the time of the survey.
Failure to Investigate and Follow Up on Missing Resident Items
Penalty
Summary
The facility failed to properly investigate and follow up on missing personal items for a resident with severe cognitive impairment and total dependence for mobility and transfers. The resident's family reported missing blankets, clothing, and stuffed animals to staff, but could not recall specific staff names. The social worker designee stated she had not received any concerns or grievances regarding missing items from this resident or their family, and no concern logs were found at the front desk as required by facility policy. Laundry and housekeeping staff reported that missing clothing is a frequent issue, with reports received verbally or in writing, but these notes are discarded after a search is conducted, and there is no documentation or follow-up. Clothing items without names accumulate in the laundry room, and staff are often informed of missing items by residents or families but do not maintain records or communicate outcomes. Certified nursing assistants confirmed that families had reported missing items, but after searching the laundry, no further action was taken or documented. During a resident council meeting, multiple residents confirmed that missing clothing was a widespread and ongoing problem, with little to no follow-up from staff after reports were made. Review of resident council meeting minutes showed repeated complaints about missing items and a lack of documented follow-up or resolution. The facility's grievance policy requires all grievances to be recorded, investigated, and maintained, but this process was not followed for missing items, resulting in unresolved concerns for residents.
Failure to Provide Timely Wound Care, Pain Management, and Assessment
Penalty
Summary
Facility staff failed to provide appropriate wound care and pain management for multiple residents, as evidenced by direct observations, interviews, and record reviews. For one resident with bilateral lower extremity venous ulcers, wound dressings were not dated as required by facility policy, and there was no documentation or evidence that wound care was performed daily as ordered by the physician. Staff interviews confirmed that wound dressings were not dated, and the Treatment Administration Record lacked documentation of wound care on specific days. The Director of Nursing verified that wound care was not completed as required. Another resident with a left heel wound and diabetic foot ulcer did not receive weekly wound assessments as outlined in the care plan. Documentation showed that after a certain date, no further weekly wound assessments were completed, and there were no wound measurements from outside wound care appointments. The Director of Nursing confirmed the lack of weekly wound evaluations, and the facility's wound care policy did not specify the required frequency for wound assessments. A third resident receiving hospice care did not receive pain medication during a painful catheter reinsertion procedure, despite expressing pain and having PRN pain medication available. The hospice nurse did not offer pain medication before or during the procedure, and the resident repeatedly verbalized pain. Additionally, staff failed to address a change in the resident's condition, as deep redness was observed in the peri area, buttocks, and under the breasts, but no treatment orders were obtained or implemented at the time. Staff interviews confirmed these deficiencies in care and communication.
Failure to Provide Timely Catheter Care and Notify Physician of Changes in Condition
Penalty
Summary
A resident with multiple complex medical conditions, including heart failure, bilateral leg amputations, obesity, diabetes with polyneuropathy, and neurogenic bladder, was admitted to the facility and received hospice services. The resident was dependent on staff for all activities of daily living and had an indwelling catheter in place. The care plan included monitoring for signs and symptoms of urinary tract infection (UTI) and ensuring catheter patency and urinary output every shift. Despite these interventions, documentation revealed that the resident exhibited symptoms of a possible UTI, such as cloudy and foul-smelling urine, increased confusion, and agitation. A urine sample was collected for urinalysis and culture, but there was no timely follow-up or documentation of the results, and neither the primary care physician nor hospice was notified promptly of the findings, which later showed significant bacterial growth requiring antibiotic treatment. On a separate occasion, the resident was found by staff to have removed her indwelling catheter, resulting in visible blood and blood clots in her brief and on the bed. The catheter, with an inflated balloon, was observed lying on the mattress. Despite the resident's change in condition and the presence of trauma, the nurse on duty did not immediately assess or address the situation, citing workload and staffing shortages. The nurse delayed reinsertion of the catheter, waiting for hospice staff to arrive, and did not notify the primary physician of the catheter removal. When hospice staff attempted to reinsert the catheter, proper infection control procedures were not followed, and the catheter was not successfully placed on the first attempt. The resident subsequently removed the catheter again, and there was continued delay in assessment and notification of the physician. Throughout these events, there was a lack of timely assessment, intervention, and communication with the primary care physician and hospice regarding significant changes in the resident's condition, including catheter removal, signs of infection, and laboratory results. The facility failed to ensure appropriate catheter care, prompt response to changes in condition, and effective communication, which affected the resident directly and had the potential to impact other residents with indwelling catheters.
Failure to Prevent Significant Medication Errors in Medication Administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by two separate incidents involving medication administration. For one resident with multiple diagnoses including heart failure and Alzheimer's disease, staff did not obtain daily weights as ordered by the physician on multiple occasions. Additionally, when the resident experienced weight gains greater than three pounds in 24 hours, the as-needed Lasix was not administered as prescribed. The Director of Nursing confirmed that both the daily weights and the administration of Lasix were not completed according to physician orders. Facility policy required medications to be administered safely, timely, and as prescribed, which was not followed in this case. In another incident, a resident with type two diabetes mellitus and moderate cognitive impairment was ordered to receive Humalog insulin via pen, including a sliding scale for blood sugar regulation. During observation, an RN administered insulin without priming the insulin pen as required by manufacturer instructions. The RN acknowledged the omission during a concurrent interview. Facility policy indicated that nursing staff should have access to manufacturer instructions for insulin administration. These failures were identified during a complaint investigation and had the potential to affect additional residents receiving insulin via pen.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure all required personal protective equipment (PPE) was available and used for residents on contact precautions, failed to implement enhanced barrier precautions as required, and failed to ensure residents were screened for tuberculosis infection as required. This affected four residents reviewed for infection control practices. The census was 41. Resident #10 was admitted with multiple diagnoses including osteomyelitis, bacteremia, and ESBL resistance. Despite being on contact isolation for ESBL, the isolation cart outside the resident's room lacked gloves and gowns. LPN #110 confirmed the absence of these items and admitted to only wearing gloves while administering medication due to the unavailability of gowns. The supply room also lacked isolation gowns. Additionally, Resident #10 had not undergone the required two-step Mantoux screening for tuberculosis. Resident #30, diagnosed with severe malnutrition and respiratory failure, was also on contact isolation for ESBL. Similar to Resident #10, the isolation cart outside Resident #30's room lacked gloves and gowns. LPN #120 confirmed the absence of these items and admitted to only wearing gloves while administering medication. Resident #30 also had not undergone the required two-step Mantoux screening for tuberculosis. Furthermore, the facility failed to implement enhanced barrier precautions for residents with wounds requiring dressings, as confirmed by LPN #120 and the Director of Nursing (DON). Resident #50 and Resident #60, both with significant wounds, were not placed under any type of isolation precautions, and neither had been screened for tuberculosis as per the facility's policy.
Failure to Offer Annual Influenza Vaccination
Penalty
Summary
The facility failed to ensure that residents were offered influenza vaccinations annually as required. This deficiency was identified during a review of Resident #40's medical record, which revealed that the resident, who was admitted with multiple diagnoses including schizophrenia, chronic obstructive pulmonary disease, type two diabetes, dementia, anemia, delusional disorder, auditory hallucinations, and a complete traumatic amputation of the left lower leg at the knee level, did not receive an influenza vaccination nor had the resident declined it during the past influenza season. The last documented influenza vaccination for Resident #40 was dated 10/14/22, and the quarterly Minimum Data Set (MDS) indicated that the resident was cognitively intact and had not been offered the vaccination. An interview with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed that Resident #40 had not received the influenza vaccination nor had they declined it. The facility's influenza vaccine policy, dated 2002, mandates that all residents and employees who have contact with residents be offered the influenza vaccine annually between October 1st and November 30th, unless medically contraindicated or refused for personal or religious reasons. The policy also requires appropriate documentation in the residents' medical records indicating the date of receipt or refusal of the vaccination. This policy was not followed in the case of Resident #40.
Failure to Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to offer the COVID-19 vaccination or obtain documentation of residents' vaccination status for three residents. Resident #10, who was admitted with multiple diagnoses including osteomyelitis, bacteremia, and pneumonia, had no documented COVID-19 vaccinations, history of vaccinations, or declination of vaccinations in their medical record. Similarly, Resident #30, admitted with severe calorie protein malnutrition and acute respiratory failure, also had no documented COVID-19 vaccination status. Resident #50, who had diagnoses including anemia, metabolic encephalopathy, and an unstageable pressure ulcer, had no documentation of COVID-19 vaccinations or declination in their medical record. All three residents were noted to be cognitively intact or had mild cognitive impairment according to their MDS assessments. The deficiency was confirmed through an interview with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN), who verified the lack of documentation for the COVID-19 vaccination status or declination for the three residents. The facility census at the time was 41, and the deficiency was investigated under Complaint Number OH00153390.
Immediate Jeopardy Due to Financial Mismanagement Impacting Essential Services
Penalty
Summary
The facility in question was found to be in Immediate Jeopardy due to financial mismanagement that resulted in unpaid bills to various vendors, leading to potential interruptions in essential services for residents. The deficiency stemmed from a pattern of delayed payments to vendors, including therapy services, food vendors, staffing agencies, and utility providers. The facility's financial instability was exacerbated by a low census, staff turnover, and challenges in completing necessary assessments for billing purposes. The lack of timely payments resulted in critical services being suspended, such as therapy services for residents, food delivery, and even the threat of utility disconnection. Key personnel, including the Administrator, CEO, and Business Office Manager, were interviewed and revealed a lack of oversight and accountability in managing the facility's finances. The CEO acknowledged the cash flow issues but failed to implement a plan to address the outstanding balances and ensure timely payments to vendors. The facility's Board of Directors was aware of the financial challenges but did not take decisive action to rectify the situation, leading to a cascading effect on resident care and services. Residents were directly impacted by the deficiency, with some requesting discharge due to the lack of therapy services and essential supplies. The deficiency extended beyond financial implications, affecting essential services such as therapy, food delivery, staffing, and even communication due to phone service interruptions. The facility's inability to meet its financial obligations jeopardized the well-being and safety of residents, as evidenced by residents not receiving necessary therapy services, facing food shortages, and experiencing disruptions in communication with their families.
Failure to Ensure Privacy and Communication Access
Penalty
Summary
The facility failed to ensure resident mail was delivered unopened and that residents had access to a private working telephone. Observations revealed that the Business Office Manager's desk contained opened mail addressed to several residents. The CEO admitted to opening the mail, believing it was permissible for Medicaid and Medicare correspondence. The facility's policy indicated that residents had the right to receive and send sealed, unopened correspondence, which was not adhered to in this instance. Additionally, the facility's phone system was not operational, preventing residents from making or receiving calls. Staff confirmed that they had to use personal cell phones for communication, including contacting physicians. Several residents reported relying on the facility phone to communicate with family members, and some did not have personal cell phones. The phone service provider indicated that the service was interrupted due to an outstanding balance and a broken contract, requiring a significant payment to resume services. Interviews with the Administrator revealed a lack of awareness regarding the phone system's status and the CEO's efforts to resolve the issue. Despite attempts to contact the facility over several days, the phone system remained non-functional. The Administrator indicated that the CEO was working on obtaining a new phone company, but no timeline or details were provided. The facility's failure to maintain a working phone system and ensure the privacy of resident mail represents non-compliance with their policies and regulations.
Staffing Deficiency Due to Hostile Work Environment and Financial Issues
Penalty
Summary
The facility failed to maintain sufficient levels of staff to meet the total care needs of all residents due to a hostile work environment and insufficient funds to maintain staffing agency contracts. Interviews with various staff members, including the scheduler, CEO, and former MDS nurse, revealed that the facility was heavily reliant on agency staff to cover nursing shifts. However, due to non-payment of agency bills, the facility was unable to continue using agency staff, leading to numerous unfilled nursing shifts from 04/01/24 to 04/30/24. This resulted in delayed resident care, including answering call lights and providing incontinence care in a timely manner. The report also highlighted significant staff turnover and resignations, including the former MDS nurse, business office manager, and several other key administrative and nursing staff. Interviews with these individuals revealed concerns about a hostile work environment, including allegations of fraud, retaliation, and unethical behavior by administrative staff. The facility's CEO was reported to have created increased anxiety and panic among the staff by communicating financial issues and stating that the facility's bank accounts were frozen, leading to further staff call-offs and concerns about receiving paychecks. Additionally, the facility's phones were disconnected, causing family members to contact staff on their personal cell phones with concerns about resident care. The facility's wide assessment form indicated that the staffing levels were not being met, and the facility's admission agreement stated that it would provide necessary care and services, which it failed to do. The deficiency was investigated under Complaint Numbers OH00152329 and OH00152153.
Failure to Maintain Full-Time Director of Nursing
Penalty
Summary
The facility failed to ensure a registered nurse (RN) served as a full-time director of nursing (DON), which had the potential to affect all 56 residents residing in the facility. The previous DON worked only 7.50 hours on one day and 6.75 hours on another day before the facility was left without a DON from early December to mid-March. During this period, the facility did not have a full-time DON, and the RN staff currently working in the building did not want to take on the role. An interim DON was brought in on March 18, but she requested a new assignment due to feeling uncomfortable with the CEO's questioning about her taking the full-time DON position. The interim DON's contract was set to end on April 18, and there was no evidence that the facility had a plan in place to secure a new DON or interim DON after that date. Interviews with the Administrator and the interim DON confirmed the lack of a full-time DON during the specified period. The interim DON's discomfort with the CEO's questioning led her to request a new assignment, and her staffing agency confirmed that her contract would not be extended. This deficiency was investigated under Complaint Numbers OH00152205 and OH00152153, highlighting the facility's failure to maintain a full-time DON as required by regulations.
Failure to Provide Rehabilitative Services Due to Payment Issues
Penalty
Summary
The facility failed to ensure residents were provided with necessary rehabilitative services, including physical therapy, speech-language pathology, and occupational therapy. This deficiency affected 19 residents and had the potential to impact all 56 residents in the facility. The issue arose due to the facility's failure to make timely payments to the contracted therapy vendor, resulting in the termination of therapy services. Despite partial payments made in March, the facility was still past due by $55,180.95 for services rendered in January and February. Consequently, the therapy vendor terminated services on April 5, 2024, leaving residents without necessary rehabilitative care. Several residents, including those with severe cognitive impairments and conditions such as dementia, diabetes, cerebral infarction, and hemiplegia, were directly affected. For instance, one resident receiving speech therapy for dysphagia and another receiving gait training were left without services from April 6 to April 12, 2024. Interviews with residents and staff confirmed the lack of therapy services, and some residents requested discharge due to the unavailability of these essential services. As of mid-April, the facility had not secured a new therapy provider, and negotiations with potential vendors were still ongoing.
Failure to Ensure Effective Governing Body and Financial Management
Penalty
Summary
The facility failed to ensure an effective governing body that was legally responsible for establishing and implementing policies regarding the management and operation of the facility, including compliance with all financial obligations for the delivery of care. The Administrator, who began employment on 03/20/23, indicated she did not handle any financial aspects of the facility. The CEO and the Board of Directors were responsible for the financial management, but the facility faced significant cash-flow problems, resulting in payment delays to multiple vendors. This affected the delivery of essential services, including food, therapy, and utilities, potentially impacting all 56 residents in the facility. Interviews with the CEO and Business Office Manager revealed that the facility was on payment plans with multiple vendors due to cash-flow issues. The Business Office Manager noted that the facility was unable to process payments for resident care and that bills were not paid timely. Outstanding balances to various vendors totaled $271,963.63, leading to service interruptions, including a water shut-off notice, phone service interruption, food delivery hold, and termination of therapy services. A Board Member confirmed that financial issues were discussed in board meetings, but there was no awareness of disconnection notices. The Administrator confirmed that she did not govern or manage the business office manager or human resources manager, and these positions reported to the CEO. The Administrator-Skilled Nursing/Assisted Living agreement indicated that the Administrator was responsible for the overall operation of the facility, including financial aspects, but this was not being effectively managed. The facility did not have a policy on the governing body to provide during the investigation.
Failure to Ensure Financial Solvency and Continuous Evaluations
Penalty
Summary
The facility failed to ensure continuous evaluations were in place to verify financial obligations were met as planned, which could potentially disrupt resident care and services. The Medical Director was unaware of the facility's financial issues and confirmed that no concerns were raised about supplies, food, medications, or resident care during the recent QAPI meeting. The CEO revealed that the facility had a cash flow issue due to changes in management, including the recent resignation of the MDS coordinator and the Business Office Manager, which led to delays in completing resident MDS assessments and generating payments for resident care. The CEO admitted that no QAPI meeting was initiated to develop a plan to ensure timely vendor payments, and the facility was considering options such as finding new staff or shutting down the facility. During an on-site investigation, it was found that the facility had a general fund balance of $6,971.18 and owed a total of $271,963.63 to various vendors, including registered dietitians, supply vendors, staffing vendors, pharmacy collections, medical supplies, food vendors, IT services, therapy services, phone services, monitoring services, oxygen vendors, and water/sewer services. Delinquent balances led to a water shut-off notice, phone service interruption, food delivery hold, and termination of therapy services. The facility's Performance Improvement Committee policy and procedure, revised in 2007, required the establishment of a committee to monitor and evaluate the quality of care, but the facility failed to address the financial solvency issues through this committee.
Failure to Provide Quarterly Resident Fund Statements
Penalty
Summary
The facility failed to provide residents with quarterly statements of their resident trust fund accounts. This deficiency affected eighteen residents who had resident fund accounts. A review of the Trust-Current Account Balance form dated 04/01/24 revealed that these residents were not given quarterly balance statements. During an interview, the Administrator confirmed that the quarterly statements were not provided and could not specify when the last statements were issued. Additionally, interviews with two residents confirmed that they had not received their quarterly fund statements. The facility's Resident Rights policy, dated 03/21/24, states that residents may maintain a resident fund account for day-to-day expenses, but this policy was not followed as required. This deficiency was investigated under Complaint Number OH00151839.
Failure to Disperse Resident Funds Timely
Penalty
Summary
The facility failed to ensure that resident fund accounts were finalized and dispersed within 30 days as required, affecting seven discharged residents. Resident #92 was admitted with Alzheimer's disease and muscle weakness, and was discharged after being admitted to the hospital for sepsis. The resident's fund balance of $40.00 was not returned within the required timeframe. Similarly, Resident #93, who had major depressive disorder and muscle weakness, was discharged with family, but their fund balance of $45.90 was not returned within 30 days. Resident #94, who had abnormal posture and dementia, passed away, and their fund balance of $2,146.88 was not returned to the estate within the required period. Resident #95, with chronic obstructive pulmonary disease and diabetes, was discharged with family, but their fund balance of $40.00 was not returned timely. Resident #96, who had sarcopenia and dementia, was transferred to another facility, but their fund balance of $3,788.40 was not returned within 30 days. Resident #97, with Alzheimer's disease and hypertension, was discharged to their wife, but their fund balance of $10.00 was not returned within the required timeframe. Lastly, Resident #98, with Alzheimer's disease and anxiety disorder, was admitted to the hospital and did not return, but their fund balance of $60.00 was not returned within 30 days. Interviews with the Business Office Manager confirmed that the trust fund monies for these residents were not returned to the residents or their representatives within the required 30-day period. The facility's Resident Rights policy allows residents to maintain a fund account for personal expenses, but the facility failed to comply with the policy by not dispersing the funds within the stipulated timeframe. This deficiency was identified through a review of medical records and trust account balance forms, highlighting a systemic issue in the management of resident funds upon discharge, eviction, or death.
Failure to Provide and Obtain Signed Admission Documentation
Penalty
Summary
The facility failed to ensure that residents admitted were provided with a description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources, as well as information concerning Medicare and Medicaid eligibility and coverage. This deficiency affected 41 residents whose records were reviewed for admission documentation. The review revealed that the Consent to Treatment and Other Acknowledgements form was not signed by the resident or their representative, nor was it witnessed by a facility representative. Additionally, the Nursing Home Admission Agreement, which describes the daily room rate, the right to an assessment of resources, and the authorization to bill Medicaid or Medicare for services rendered, was also not signed or witnessed as required. For instance, Resident #2 was admitted with diagnoses including hypertension, heart failure, and chronic kidney disease. The admission documentation for this resident lacked the necessary signatures on both the Consent to Treatment and Other Acknowledgements form and the Nursing Home Admission Agreement. Similar deficiencies were found in the records of other residents, such as Resident #3, who was admitted with hyperglycemia, diabetes, and hypertension, and Resident #5, who was admitted and readmitted with diagnoses including encephalopathy, chronic obstructive pulmonary disease, and hypertension. In each case, the required forms were not signed by the resident or their representative, nor were they witnessed by a facility representative. The issue was confirmed during an interview with Social Service Designee (SSD) #828, who acknowledged that the facility did not ensure the 41 residents had signed admission agreements. This lack of signed documentation resulted in the facility not having consent to bill Medicare/Medicaid for services rendered or a consent to treat while the residents were admitted. This deficiency represents non-compliance investigated under Complaint Number OH00151839.
Failure to Complete Timely Comprehensive Assessments
Penalty
Summary
The facility failed to ensure initial comprehensive assessments were completed timely and as required for seven residents. Resident #3 was admitted with diagnoses including non-traumatic subarachnoid hemorrhage, diabetes, and hypertension, but their comprehensive assessment was still in progress. Similarly, Resident #5, who was admitted and readmitted with acute kidney failure, chronic obstructive pulmonary disease, and hypertension, also had an incomplete assessment. Resident #11, admitted with end-stage renal disease, polyneuropathy, and legal blindness, had a comprehensive assessment that was due but not completed on time. Resident #22, with unspecified dementia, hyperlipidemia, and essential hypertension, also had an incomplete assessment. Resident #45, admitted and readmitted with type two diabetes and unsteadiness on the feet, had an overdue comprehensive assessment. Resident #130, admitted and discharged with Crohn's disease and age-related physical debility, had an incomplete discharge assessment. Lastly, Resident #133, admitted and discharged with diseases of the tongue, bipolar disorder, and dysphagia, also had an incomplete assessment. Interviews with the Business Office Manager and the Administrator confirmed that the comprehensive assessments for these residents were not completed timely. The assessments were either still in progress or overdue, indicating a failure in the facility's process to ensure timely and required initial comprehensive assessments. This deficiency affected seven out of the 24 residents reviewed for comprehensive assessments, highlighting a significant lapse in the facility's compliance with assessment requirements.
Failure to Complete Quarterly Comprehensive Assessments
Penalty
Summary
The facility failed to ensure comprehensive assessments were completed quarterly as required, affecting four residents. Resident #13, initially admitted with chronic respiratory failure, other lack of coordination, and diabetes, had an incomplete quarterly Minimum Data Set (MDS) 3.0 comprehensive assessment. This was confirmed by the Business Office Manager (BOM) during an interview. Similarly, Resident #33, with diagnoses including chronic obstructive pulmonary disease, muscle wasting, and major depressive disorder, also had an incomplete quarterly MDS 3.0 assessment, as confirmed by the Administrator during an interview. Resident #90, admitted with Parkinson's disease, heart failure, and anemia, had an incomplete discharge MDS 3.0 assessment, which was confirmed by the Administrator. Lastly, Resident #126, with end-stage renal disease, lack of coordination, and unsteadiness on the feet, had an incomplete Discharge Return Anticipated comprehensive assessment. This was confirmed by the BOM. These deficiencies indicate a failure to complete required comprehensive assessments in a timely manner for the affected residents.
Failure to Reconcile Medications Upon Discharge
Penalty
Summary
The facility failed to ensure that Resident #90's discharge summary included the reconciliation of the resident's medications upon discharge. Resident #90, who had diagnoses including Parkinson's disease, heart failure, and anemia, was admitted on an unspecified date and discharged on 02/16/24. The discharge summary did not include a list of the resident's current medications or the last dose administered, and this information was not provided to the resident or their representative upon discharge. This was confirmed by the Administrator during an interview on 03/28/24. Additionally, Resident #90's wife reported that at the time of discharge, the facility handed her paperwork to sign without going over the discharge part of the paperwork, including the resident's medication list. The facility's undated Discharge Policy and Procedure stated that residents had the right to be informed of policies at the time of admission, transfer, and/or discharge, and that written communication would be provided to ensure a safe and orderly process. This deficiency was investigated under Complaint Number OH00151839.
Failure to Provide Ordered Food Items
Penalty
Summary
The facility failed to provide Resident #29 with food items as ordered and planned. Resident #29, who was admitted with diagnoses including Alzheimer's disease, anemia, and dysphagia oropharyngeal phase, had a physician's order for a regular diet with pureed texture, thin liquids with no straw, and ice cream with all meals. Despite this, the resident did not receive ice cream from 04/11/24 to 04/15/24 because the facility ran out of ice cream on 04/10/24 and was unable to purchase more due to a maxed-out credit card. This was confirmed by the Dietary Kitchen Manager during an interview on 04/15/24, who stated that ice cream would be delivered with the food delivery truck on 04/17/24. The deficiency was investigated under Complaint Number OH00152329.
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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) |
|---|---|---|---|---|
| Liberty Nursing Center Of Mansfield | 1.2 mi | ★★★★★ | 0 | 0 |
| Winchester Terrace | 1.6 mi | ★★★★★ | 3 | 0 |
| Crystal Care Center Of Mansfie | 2.3 mi | ★★★★★ | 0 | 0 |
| Arbors At Mifflin | 4.3 mi | ★★★★★ | 0 | 0 |
| Oak Grove Manor | 4.3 mi | ★★★★★ | 4 | 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.