Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Liberty Nursing Center Of Mansfield during CMS and state inspections, most recent first.
The facility failed to timely implement its bowel protocol for two residents who had not had bowel movements, resulting in one resident experiencing actual harm including abdominal pain, fecal emesis, and hospitalization for dehydration and constipation, while another was placed at risk. Despite care plans and physician orders, prescribed interventions such as Milk of Magnesia, Bisacodyl suppository, and Fleet enema were not administered, and staff did not document required assessments or communicate bowel status as required by facility policy.
Surveyors found that the kitchen dishwashing area was not maintained in a clean and sanitary condition, with visible buildup of substances on a pipe, a puddle of water in a corner, and excessive dirt and debris under a rubber mat. These conditions were confirmed by a dietary staff member and had the potential to affect all residents receiving food from the kitchen.
The facility did not ensure all staff received annual education or vaccine information sheets regarding the COVID-19 vaccine, nor did it document that 54 of 79 staff were offered the vaccine as required. Staff were told to obtain the vaccine from outside providers, and only new hires were asked about the vaccine upon employment. This deficiency had the potential to affect all residents.
Several residents with conditions such as depression, dementia, and schizoaffective disorder were prescribed antidepressant medications, but nursing staff did not document monitoring for effectiveness or adverse effects as required by care plans and physician orders. Despite expectations from the DON and Medical Director, and the presence of relevant care plan interventions, there was no evidence in nurse's notes or MARs that such monitoring was performed for any of the affected residents.
A resident with intact cognition and multiple medical conditions requested to receive showers at least three times per week, but was only scheduled and provided with two showers weekly according to the facility's set schedule. Despite the resident's expressed preference and facility policy supporting resident choice in bathing frequency, staff interviews and documentation confirmed the request was not accommodated.
A resident with intact cognition and significant medical conditions reported to an LPN that a CNA had engaged in inappropriate sexual contact during incontinence care. The incident was reported internally, the CNA was suspended and later terminated, and the resident's family and physician were notified. However, the facility did not report the allegation to local law enforcement as required by policy, instead deferring to the resident's and family's wishes. This failure to notify authorities was a breach of required abuse reporting protocols.
A resident with severe cognitive impairment and multiple medical conditions received a new diagnosis of psychotic disorder with hallucinations, but the facility did not complete a required PASARR evaluation following this significant change in mental health status. Staff confirmed that no level two PASARR was conducted, contrary to facility policy.
A resident with multiple health conditions and a recent fall did not receive the recommended specialized rehabilitative services, specifically a tilt wheelchair, after therapy staff identified the need. Despite the resident's ongoing complaints and the poor condition of the current wheelchair, there was no evidence that therapy staff followed through with trialing or obtaining the appropriate equipment.
A resident with diabetes experienced multiple episodes of high blood sugar, leading to several doses of Humulin insulin being administered per provider orders. However, the LPN did not document the times of administration or blood sugar rechecks in the electronic medical record or on the MAR, and the facility's policy requiring such documentation was not followed. The DON and nurse practitioner confirmed the lack of proper documentation.
Several residents signed arbitration agreements that did not include a provision for selecting a venue convenient to both parties, as required. This omission was confirmed by the Administrator and affected multiple agreements reviewed during the survey.
Surveyors observed that staff failed to maintain proper infection control practices, including leaving urinary catheter drainage bags on the floor and not using required PPE during high-contact care and when entering rooms of residents on contact or enhanced barrier precautions. These lapses occurred despite clear facility policies and care plans, and staff acknowledged the failures during interviews.
Two residents with chronic medical conditions were not offered the recommended pneumococcal conjugate vaccines (PCV15, PCV20, or PCV21) one year after receiving PPSV23, as required by CDC guidelines. This failure was confirmed by nursing staff and was not in accordance with the facility's own policy.
Staff failed to follow safe transfer protocols for three residents requiring Hoyer lifts, including transferring a resident alone without required assistance, using mechanical lifts with uncharged batteries leading to stalled transfers, and not fully opening lift legs for stability. These actions were inconsistent with facility policy and manufacturer instructions, resulting in unsafe transfer practices.
Failure to Timely Implement Bowel Protocol Resulting in Harm
Penalty
Summary
The facility failed to implement its bowel protocol in a timely manner for residents who had not had bowel movements, resulting in actual harm to one resident and placing another at risk for harm. For one resident with Parkinson's Disease, peripheral vascular disease, and dementia, there was no recorded bowel movement for five days. Despite care plan interventions and physician orders specifying a stepwise bowel protocol to be initiated after three days without a bowel movement, there was no evidence that any of the prescribed interventions—Milk of Magnesia, Bisacodyl suppository, or Fleet enema—were administered. Documentation and staff interviews confirmed that the bowel protocol was not followed, and no assessment for constipation or bowel sounds was documented during this period. The resident subsequently experienced abdominal pain and multiple episodes of emesis with fecal odor, prompting transfer to the emergency room. Hospital records indicated the resident was admitted for dehydration and constipation, with imaging revealing a moderate to large amount of retained stool and possible fecal impaction. Interviews with staff, including the RN, CNA, ADON, DON, and NP, confirmed that the bowel protocol was not implemented as required, and communication lapses occurred regarding the resident's bowel status. The DON and ADON acknowledged that the protocol should have been initiated and that the necessary medications were available but not administered. A second resident with a diagnosis of constipation also did not receive timely intervention after three days without a bowel movement, as required by the facility's bowel protocol. The resident reported not receiving requested interventions such as prune juice or a laxative. Review of records confirmed that the bowel protocol was not implemented, and the DON verified that interventions should have been provided. The facility's policy required monitoring and prompt intervention for constipation, but this was not followed for either resident, as evidenced by the lack of documentation and administration of prescribed treatments.
Unsanitary Kitchen Conditions Observed
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and sanitary kitchen environment. During an inspection of the dishwashing area, a pipe along the lower part of the wall was found with a buildup of black, white, and grey substances. Additionally, a dark puddle of water was present in the corner where the walls met. The rubber mat in the dishwashing area, designed with circular holes for drainage, had an excessive amount of dirt, buildup, and debris visible through the holes and underneath the mat. These findings were confirmed by a dietary staff member during the observation. The unsanitary conditions in the kitchen had the potential to affect all 57 residents who received food from the kitchen, with one resident identified as receiving nothing by mouth. The facility census at the time was 58.
Failure to Provide Annual COVID-19 Vaccine Education and Documentation for Staff
Penalty
Summary
The facility failed to ensure that all staff received education and vaccine information sheets regarding the COVID-19 vaccine, as required by policy and CDC/FDA guidelines. Out of 79 staff members, there was no documentation that 54 had been offered the annual COVID-19 vaccine or received education about its risks and benefits. Only 25 new staff hired since September 1, 2024, had received some education and declined the vaccine, but there was no evidence that any staff were provided with the vaccine information sheet. Interviews with staff, including RNs, the Administrator, and the Human Resource Manager, confirmed that the facility did not provide annual education or offer the vaccine to staff, instead instructing them to obtain it from their own pharmacy or physician. Further review of the facility's COVID-19 Vaccine Policies and Procedures indicated that all staff should be offered the vaccine annually and provided with education and a vaccine information sheet, with documentation maintained for all staff. However, the Administrator and HRM acknowledged that staff were only asked about the vaccine upon hire and not annually, and that the required education and information sheets were not provided. This deficiency affected 54 of 79 staff and had the potential to impact all residents, with a facility census of 58 at the time of the survey.
Failure to Monitor Effectiveness and Adverse Effects of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications, specifically antidepressants, were monitored for effectiveness and adverse consequences as required. Multiple residents with diagnoses such as depression, dementia, schizoaffective disorder, and anxiety were prescribed various antidepressant medications, including Citalopram, Trazodone, Effexor, Sertraline, Bupropion, and Duloxetine. Despite care plans and physician orders indicating the need for monitoring, there was no documentation in nurse's notes or Medication Administration Records (MARs) that such monitoring occurred for these residents over extended periods. For example, one resident with severe cognitive impairment and diagnoses of Parkinson's disease and dementia was prescribed Citalopram and Trazodone, with care plans requiring monitoring every shift. However, there was no evidence in the medical record or MARs that monitoring for effectiveness or adverse effects was performed. Similar findings were noted for other residents with major depressive disorder, schizoaffective disorder, and anxiety, all of whom had orders and care plans specifying the need for monitoring, but lacked corresponding documentation. Interviews with the DON and the Medical Director confirmed that nursing staff were expected to monitor and document the effectiveness and adverse effects of psychotropic medications, but this was not being done. Additionally, the facility did not have a specific policy for psychotropic medication use, instead relying on an antipsychotic medication policy, which did not address the broader category of psychotropic drugs. This deficiency affected all five residents reviewed for unnecessary medications, out of a total of 40 residents receiving psychotropic medications in the facility.
Failure to Honor Resident's Shower Frequency Preference
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's expressed preference for shower frequency. The resident, who had intact cognition and required supervision for showering, was scheduled for showers twice weekly on specific days and shifts, as indicated by the facility's shower schedule and documentation. Despite the resident's request, made known during a care conference and to the Social Services Designee, to receive showers at least three times per week, the facility continued to provide and schedule only two showers per week. The facility's shower schedule included a note instructing staff not to change shower days for residents, and the schedule matched what was listed in the electronic medical record. Interviews with the resident, the Social Services Designee, and a Registered Nurse confirmed that the resident's request for increased shower frequency was not accommodated. The facility's policy stated that residents have the opportunity to express their preference for bathing type, frequency, and time of day, but this policy was not followed in the resident's case. The failure to support the resident's choice regarding shower frequency was identified through medical record review, staff and resident interviews, and review of facility documentation.
Failure to Report Sexual Abuse Allegation to Law Enforcement
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to local law enforcement, as required by policy and regulation. A resident with intact cognition and a history of Hodgkin's lymphoma and malnutrition reported to an LPN that a CNA had groped her breast and inserted his finger into her vaginal area during incontinence care. The LPN notified the Administrator, who then informed the DON. The resident, her family, and her physician were notified, and the resident declined to be sent to the hospital. The CNA in question was suspended and later terminated, but the incident was not reported to local law enforcement or other agencies, despite the facility's policy requiring such action when a crime is suspected. The investigation revealed that the resident was upset and requested no male caregivers following the incident. The facility's documentation showed that the resident and her family declined police involvement, citing embarrassment and a desire for privacy. However, the facility did not offer alternative arrangements for the resident to speak with law enforcement in a more private setting. Interviews with staff and other residents indicated that some residents had negative impressions of the CNA, and another resident described an uncomfortable experience with the same CNA, though she had not previously reported it. The facility's policy clearly stated that suspicions of a crime, including sexual abuse, must be reported to local police immediately, in addition to notifying the state health department and the resident's family and physician. Despite this, the facility did not notify law enforcement, relying instead on the resident's and family's wishes. The omission of this required reporting constituted a failure to follow established protocols for handling allegations of abuse, potentially affecting the safety and well-being of all residents in the facility.
Failure to Complete PASARR After New Psychiatric Diagnosis
Penalty
Summary
The facility failed to complete a required Pre-admission Screening and Resident Review (PASARR) evaluation after a resident received a new diagnosis of psychotic disorder with hallucinations due to a known psychological condition. The resident, who had previously been admitted with diagnoses including Parkinson's Disease, peripheral vascular disease, and dementia, was found to be severely cognitively impaired according to a recent Minimum Data Set (MDS) assessment. Although the initial PASARR was completed prior to admission, there was no evidence in the medical record of a subsequent PASARR evaluation following the new psychiatric diagnosis. Staff interview confirmed that no level two PASARR evaluation or determination was conducted after the significant change in the resident's mental health status, despite facility policy requiring notification of the state mental health authority after such changes.
Failure to Provide Recommended Rehabilitative Services and Equipment
Penalty
Summary
The facility failed to implement recommended specialized rehabilitative services for a resident who had a history of muscle wasting, heart disease, osteoarthritis, unsteadiness, and postural kyphosis. After the resident sustained a fall from their wheelchair, a physician ordered a physical therapy evaluation and treatment. The physical therapy evaluation identified the need for a possible tilt chair to decrease the resident's fall risk, following a noted decline and the resident's report of sliding out of the wheelchair due to a bed pad. Despite this recommendation, there was no evidence that a tilt chair was trialed or that further action was taken to address the resident's wheelchair needs. The resident, who was cognitively intact and required assistance from at least two staff for bed mobility and transfers, reported ongoing issues with the condition of their wheelchair and stated that therapy staff were supposed to be working on obtaining a new wheelchair. Observation confirmed the wheelchair was in poor condition, with missing material and tape applied by the resident. The Therapy Director verified that although therapy staff had planned to trial a different wheelchair, there was no documentation or evidence that this was ever initiated or completed.
Failure to Accurately Document Insulin Administration and Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure appropriate and accurate documentation in the electronic medical records for a resident with diabetes and atherosclerotic heart disease. The resident was admitted with orders for Lantus insulin, which was later adjusted, but did not have routine blood sugar checks ordered. On one occasion, the resident experienced critically high blood sugar readings, and a series of orders were given by a nurse practitioner to administer multiple doses of Humulin insulin and to recheck blood sugars. The progress note documenting these events did not include the times of provider notification, when orders were received, the times of insulin administration, or the times of blood sugar rechecks. Further review revealed that none of the Humulin doses administered were entered into the electronic medical record or recorded on the Medication Administration Record (MAR). Interviews with the resident, the LPN involved, the DON, and the nurse practitioner confirmed that the insulin orders and administrations were not properly documented in the electronic system, and that facility policy required blood glucose monitoring results to be recorded in the MAR. The lack of documentation affected the accuracy and completeness of the resident's medical record.
Arbitration Agreements Lacked Required Venue Selection Provision
Penalty
Summary
The facility failed to include all required components in its arbitration agreements for residents, specifically omitting provisions for the selection of a venue convenient to both parties. This deficiency was identified through a review of medical records and signed arbitration agreements for five residents, where each agreement lacked the necessary clause regarding venue selection. The issue was confirmed during an interview with the Administrator, who acknowledged that the agreements did not contain this required element. A total of 33 residents had entered into arbitration agreements, and the deficiency was found in five of the seven residents reviewed for this component. The omission was consistent across multiple agreements, regardless of the residents' admission dates. The facility census at the time was 58 residents.
Failure to Follow Infection Control Protocols for Catheter Care and PPE Use
Penalty
Summary
Surveyors identified multiple deficiencies related to infection prevention and control practices. For one resident with a history of mechanical complication of a knee prosthesis, benign prostatic hyperplasia, and neuromuscular bladder dysfunction, observations revealed that the indwelling urinary catheter drainage bag was lying on the floor, contrary to physician orders and facility policy, which require the bag to be secured below the bladder and not in contact with the floor. Staff interviews confirmed awareness of the correct procedure, but the required practice was not followed. Another resident with Parkinson's disease, peripheral vascular disease, and dementia was on contact precautions due to an active infection with a highly transmissible pathogen (ESBL). Despite care plan interventions and facility policy requiring the use of personal protective equipment (PPE) upon room entry, the Administrator was observed entering the resident's room without donning any PPE. The Administrator confirmed this lapse during an interview. A third resident with diabetes, dementia, hypertension, atrial fibrillation, and obstructive uropathy had a suprapubic catheter and required enhanced barrier precautions. Observations showed the resident's catheter drainage bag was uncovered and on the floor, and staff transferring the resident did not wear the required gown and gloves during high-contact care activities, despite signage and policy indicating the need for PPE. Staff interviews confirmed knowledge of the requirements but acknowledged non-compliance during the observed care.
Failure to Administer Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
The facility failed to ensure pneumococcal vaccines were administered according to current CDC guidelines for two residents. For one resident with diagnoses including type two diabetes mellitus, COPD, atrial fibrillation, hypertension, and anxiety, the medical record showed the last pneumococcal polysaccharide vaccine (PPSV23) was administered in early 2020. Based on CDC recommendations and the resident's age and medical history, the resident should have been offered a dose of PCV15, PCV20, or PCV21 one year after the PPSV23 immunization, but this was not done. This was confirmed by a registered nurse during an interview. Similarly, another resident with heart failure, Parkinson's disease, type two diabetes mellitus, and dementia received the PPSV23 immunization in mid-2022. According to CDC guidelines, this resident should also have been offered a dose of PCV15, PCV20, or PCV21 one year after the PPSV23 immunization, but this did not occur. The facility's policy stated that pneumococcal vaccines should be administered in accordance with current CDC recommendations, but this was not followed for these two residents.
Failure to Ensure Safe Resident Transfers Using Mechanical Lifts
Penalty
Summary
The facility failed to ensure safe transfer practices for residents requiring manual and mechanical Hoyer lifts, as evidenced by multiple incidents involving three residents. One resident with severe dementia and agitation was observed being transferred by a hospice aide using a Hoyer lift without the required assistance of a second staff member, contrary to the facility's policy mandating two staff for such transfers. The aide confirmed performing the transfer alone, and the policy review supported the need for two staff to ensure safety. Another resident with severe obesity and cognitive intactness reported being left suspended in the air during transfers due to mechanical lift or battery failures. Staff interviews revealed that mechanical lifts frequently lost power during transfers, requiring the use of emergency releases or battery changes mid-transfer. There was no established protocol for charging lift batteries, and staff confirmed that lifts often began beeping and slowed down during use. During an observed transfer, the lift's metal attachment nearly struck the resident's head after being unhooked, and staff acknowledged this was not an uncommon occurrence. A third resident, dependent on staff for transfers due to dementia and muscle weakness, was observed being transferred with the mechanical lift's legs in the closed position throughout the process, contrary to manufacturer instructions and facility policy, which require the legs to be fully open for stability except when maneuvering under a bed. Staff interviews confirmed awareness of the correct procedure but did not follow it during the observed transfer. These findings demonstrate a pattern of non-compliance with established safety protocols for resident transfers using mechanical lifts.
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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) |
|---|---|---|---|---|
| Winchester Terrace | 0.8 mi | ★★★★★ | 3 | 0 |
| Jag Healthcare Mansfield | 1.2 mi | ★★★★★ | 0 | 0 |
| Crystal Care Center Of Mansfie | 3.1 mi | ★★★★★ | 0 | 0 |
| Arbors At Mifflin | 5 mi | ★★★★★ | 0 | 0 |
| Oak Grove Manor | 5 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.